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Wood S, Coxon L, Glyn-Jones S, Barker KL. Neuropathic pain is a feature in patients with symptomatic femoral acetabular impingement. Physiotherapy 2024; 124:135-142. [PMID: 38896948 DOI: 10.1016/j.physio.2024.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Revised: 03/06/2024] [Accepted: 03/18/2024] [Indexed: 06/21/2024]
Abstract
Femoral acetabular impingement syndrome (FAIS) is a cause of hip pain thought to be nociceptive, although pain phenotypes e.g., burning, pain attacks, prickling, numbness etc., are reported, mimicking neuropathic pain. Although no lesion to the somatosensory system is identified, neuropathic pain (NeP) may explain why nociceptive-focussed treatments are not always successful. OBJECTIVE To identify NeP in patients with FAIS and investigate if related to poorer outcomes. DESIGN A secondary analysis of the Femoral Acetabular Impingement Trial (FAIT). Outcome of interest: PainDETECT questionnaire; secondary outcomes of interest; International Hip Outcome Tool (iHOT33), Hospital Anxiety and Depression Scale (HADS) and VAS 'average pain over a month', at baseline and 8 months follow-up. Intervention (surgery or physiotherapy) were pooled. RESULTS 173 data sets at baseline; 123 at 8 months follow-up. Baseline painDETECT identified three groups: 69% nociceptive, 19% unclear and 12% neuropathic pain phenotypes. Baseline, median scores were higher for the neuropathic group compared to the nociceptive group demonstrating borderline anxiety (9.5(5.3 to 14.2), 5(3 to 8), higher normal values for depression (7.5(2.3 to 11.8), (4(2 to 9), higher average pain (7 (6 to 8), 5(4 to 6) and lower iHOT33 14.2(9 to 21.1), 38.4(26.2 to 55.7). Post treatment, there was a median change in the neuropathic score in both iHOT33 (40.8 (25 to 76.5) with a median difference of 24.13 (CI 95% 10.46 to 45.92) and average pain 4.5(1.5 to 7) with a median difference of 2 (CI 95% 1 to 5) but to a lesser amount than the nociceptive group, iHOT33 (64(38.2 to 86.6) with a median difference of 15.50 (CI 95% 6.41 to 21.82) and average pain 3(1 to 5.7) with a median difference of 1 (CI 95% 0.5 to 1). CONCLUSION NeP exists in symptomatic FAIS patients and is associated with increased average pain, and functional limitations. Nociceptive-targeted treatment improves hip function and pain but with less improvement in the NeP group when compared to the nociceptive group. Pain phenotyping before intervention may improve outcomes. CONTRIBUTION OF PAPER.
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Affiliation(s)
- Simon Wood
- Physiotherapy Research Unit, Nuffield Orthopaedic Centre, Oxford University Hospitals FT, United Kingdom; Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford UK, United Kingdom.
| | - Lydia Coxon
- Nuffield Department of Women's and Reproductive Health, Medical Science Division, United Kingdom.
| | - Siôn Glyn-Jones
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford UK, United Kingdom.
| | - Karen L Barker
- Physiotherapy Research Unit, Nuffield Orthopaedic Centre, Oxford University Hospitals FT, United Kingdom; Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford UK, United Kingdom.
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Nickerson M, Herickhoff P. Femoroacetabular Impingement and Groin Injuries Among Soccer Players. Sports Med Arthrosc Rev 2024; 32:120-124. [PMID: 39087700 DOI: 10.1097/jsa.0000000000000394] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/02/2024]
Abstract
Groin injuries and femoroacetabular impingement are common among soccer players and can provide a challenge in diagnosis, as well as treatment. Nonoperative and operative measures are the 2 predominant treatments. This current review investigates the recent literature on groin and femoroacetabular impingement injuries in soccer players, as well as potential treatment modalities.
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Affiliation(s)
- Morgan Nickerson
- Department of Orthopedic Surgery, Penn State Health Milton S. Hershey Medical Center, State College, PA
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Chen KK, Osadebey EN, Shupe PG, Gregory BP. Hip Sideline Emergencies and Hip Injuries in Elite Athletes. Curr Rev Musculoskelet Med 2024:10.1007/s12178-024-09914-x. [PMID: 39017861 DOI: 10.1007/s12178-024-09914-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/02/2024] [Indexed: 07/18/2024]
Abstract
PURPOSE OF REVIEW Hip injuries in elite athletes are an increasingly recognized problem and range from chronic overuse injuries, such as adductor strains and labral tears, to acute traumatic injuries such as hip dislocations. In this article, we review common hip pathology experienced by elite athletes and sideline management of emergent hip injuries. RECENT FINDINGS Elite athletes are subject to unique physical and mental stresses and therefore must be evaluated and treated in a unique manner. Hip and groin injuries account for approximately 6% of sport injuries overall and 3-15% of all injuries in professional sports. Hip sideline emergencies were rare but can include hip dislocations, subluxations, and avulsion fractures. Hip and groin injuries represent an important subset of injuries which can greatly impact an athlete's ability to perform. Understanding the physiology and types of hip/groin injuries, which athletes are prone to injuries, the impact on recovery time, recurrence risk, and the potential need for surgery aid sports medicine physicians in decision-making.
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Affiliation(s)
- Kevin K Chen
- Department of Orthopaedic Surgery, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Emmanuel N Osadebey
- Department of Orthopaedic Surgery, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Paul G Shupe
- Department of Orthopaedic Surgery, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Bonnie P Gregory
- Department of Orthopaedic Surgery, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, USA.
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Alvero AB, Wright-Chisem J, Vogel MJ, Wright-Chisem A, Mather RC, Nho SJ. Treatment of Hip Cartilage Defects in Athletes. Sports Med Arthrosc Rev 2024; 32:95-103. [PMID: 38978203 DOI: 10.1097/jsa.0000000000000378] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/10/2024]
Abstract
Chondral defects in the athlete's hip are a relatively common occurrence, often presenting with debilitating pain and activity limitation. Preoperative identification of cartilage defects is challenging and there are many different modalities for treatment. Nonsurgical interventions, including activity modification, physical therapy, and injections, play a vital role, especially in less severe cases and as adjuncts to surgical intervention. Treating surgeons must be familiar with the cartilage restoration procedures available, including debridement, microfracture, and various implantation and transplantation options. Safe and effective management of cartilage defects is imperative to an athlete's return to sport. It is also imperative that surgeons are aware of all these various treatment options to determine what modality is best for their patients. This review serves to outline these options, cover the published literature, and provide general guidelines for surgeons when they encounter chondral defects in the office and the operating room.
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Affiliation(s)
- Alexander B Alvero
- Section of Young Adult Hip Surgery, Division of Sports Medicine, Department of Orthopedic Surgery, Rush Medical College of Rush University, Rush University Medical Center; Chicago, IL
| | - Joshua Wright-Chisem
- Section of Young Adult Hip Surgery, Division of Sports Medicine, Department of Orthopedic Surgery, Rush Medical College of Rush University, Rush University Medical Center; Chicago, IL
| | - Michael J Vogel
- Section of Young Adult Hip Surgery, Division of Sports Medicine, Department of Orthopedic Surgery, Rush Medical College of Rush University, Rush University Medical Center; Chicago, IL
| | - Adam Wright-Chisem
- Department of Orthopedic Surgery, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Richard C Mather
- Department of Orthopedic Surgery, Duke University Medical Center, Durham, NC
| | - Shane J Nho
- Section of Young Adult Hip Surgery, Division of Sports Medicine, Department of Orthopedic Surgery, Rush Medical College of Rush University, Rush University Medical Center; Chicago, IL
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Vasavada KD, Shankar DS, Ross KA, Avila A, Buzin S, Jazrawi IB, Carter CW, Chen AL, Borowski LE, Milton HA, Gonzalez-Lomas G. Patient-reported hip pain and function are worse among elite Nordic ski athletes competing in ski jumping versus Nordic combined: a cross-sectional analysis. J ISAKOS 2024; 9:283-289. [PMID: 38278215 DOI: 10.1016/j.jisako.2024.01.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Revised: 11/25/2023] [Accepted: 01/15/2024] [Indexed: 01/28/2024]
Abstract
OBJECTIVES Nordic ski athletes are at increased risk of developing hip pain and dysfunction secondary to femoroacetabular impingement syndrome (FAIS), but it is unclear whether hip symptomatology differs between ski jumping (SJ) and Nordic combined (NC) athletes. The purpose of this study was to compare patient-reported hip pain and dysfunction between elite Nordic ski athletes participating in SJ versus NC. METHODS A cross-sectional study was conducted involving SJ and NC athletes who competed at the international and U.S. national levels during the 2021-2022 season. Subjects were excluded if they had hip surgery within two years prior to enrollment. Subjects were asked to undergo diagnostic workups for FAIS, including physical examination and plain radiographic imaging. Subjects were asked to complete a survey that collected information on athletic and training history and to complete the hip disability and osteoarthritis outcome score (HOOS). Demographics, athletic/training history, and HOOS sub-scores were compared between the SJ and NC groups using the Student's t-test, Wilcoxon rank-sum test, or Fisher's exact test, as appropriate. p-values < 0.05 were considered significant. RESULTS Twenty-four athletes (13 SJ, 11 NC) were included in the study. There were no statistically significant differences in age, sex, BMI, or age of menarche between the two groups (all p > 0.05). There were also no statistically significant differences in the number of prior sports participated in, total hours of participation in prior sports, or total hours of training in Nordic specialization (all p > 0.05). Among the 18 athletes who underwent physical examination (9 SJ, 9 NC), there were no statistically significant inter-group differences in hip range of motion or incidence of positive impingement tests (all p > 0.05). Among the 19 athletes who underwent imaging (9 SJ, 10 NC), there were no statistically significant inter-group differences in the incidence of cam or pincer morphology in at least one hip (all p > 0.05). SJ athletes had statistically significantly worse HOOS sub-scores for hip symptoms and stiffness, hip function in sports/recreational activities, and hip-related quality of life compared to NC athletes (all p < 0.05). CONCLUSION Elite SJ athletes have worse self-reported hip function compared to elite NC athletes, despite comparable demographics, athletic history, and duration of ski training. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Kinjal D Vasavada
- New York University School of Medicine, Department of Orthopedic Surgery, New York, NY, 10029, USA.
| | - Dhruv S Shankar
- New York University School of Medicine, Department of Orthopedic Surgery, New York, NY, 10029, USA
| | - Keir A Ross
- New York University School of Medicine, Department of Orthopedic Surgery, New York, NY, 10029, USA
| | - Amanda Avila
- New York University School of Medicine, Department of Orthopedic Surgery, New York, NY, 10029, USA
| | - Scott Buzin
- New York University School of Medicine, Department of Orthopedic Surgery, New York, NY, 10029, USA
| | - Isabella B Jazrawi
- New York University School of Medicine, Department of Orthopedic Surgery, New York, NY, 10029, USA
| | - Cordelia W Carter
- New York University School of Medicine, Department of Orthopedic Surgery, New York, NY, 10029, USA
| | - Andrew L Chen
- The Alpine Clinic, Franconia, NH, 10029, USA; USA Nordic Sport, Park City, UT, 10029, USA
| | - Lauren E Borowski
- New York University School of Medicine, Department of Orthopedic Surgery, New York, NY, 10029, USA; USA Nordic Sport, Park City, UT, 10029, USA
| | - Heather A Milton
- New York University School of Medicine, Sports Performance Center, New York, NY, 10029, USA
| | - Guillem Gonzalez-Lomas
- New York University School of Medicine, Department of Orthopedic Surgery, New York, NY, 10029, USA
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Ramkumar PN, Olsen RJ, Shaikh HJF, Nawabi DH, Kelly BT. Modern Hip Arthroscopy for FAIS May Delay the Natural History of Osteoarthritis in 25% of Patients: A 12-Year Follow-up Analysis. Am J Sports Med 2024; 52:1137-1143. [PMID: 38459690 DOI: 10.1177/03635465241232154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/10/2024]
Abstract
BACKGROUND Little is known about the effect of modern hip arthroscopy on the natural history of femoroacetabular impingement syndrome (FAIS) with respect to joint preservation. PURPOSE To (1) characterize the natural history of FAIS and (2) understand the effect of modern hip arthroscopy by radiographically comparing the hips of patients who underwent only unilateral primary hip arthroscopy with a minimum follow-up of 10 years. STUDY DESIGN Cohort study; Level of evidence, 3. METHODS Between 2010 and 2012, 619 consecutive patients were reviewed from the practice of a single fellowship-trained hip arthroscopic surgeon. Inclusion criteria were FAIS, bilateral radiographic findings of femoroacetabular impingement, primary unilateral hip arthroscopy (labral repair, femoroplasty, or capsular closure), and minimum 10-year follow-up. The preoperative and minimum 10-year postoperative radiographs of patients were evaluated at each time point. Both operative and nonoperative hips were graded using the Tönnis classification or the presence of hip arthroplasty by 2 independent reviewers. Subgroup analyses were performed. RESULTS A total of 200 hips from 100 patients were evaluated at a mean follow-up of 12.0 years. Preoperatively, 98% and 99% of operative and nonoperative hips were evaluated as Tönnis grades 0 and 1, respectively; 5% of nonoperative hips had worse Tönnis grades than operative hips. The nonoperative hip advanced to a worse Tönnis grade in 48% (48/100) of cases compared with 28% (28/100) among operative hips. At follow-up, Tönnis grades between hips were equal in 70% (70/100) of the cases, the operative hip had a better grade 25% (25/100) of the time, and the nonoperative hip had a better grade 5% (5/100) of the time. Modern hip arthroscopy was associated with a relative risk reduction of 42% in osteoarthritis progression. Impingement with borderline dysplasia, age, preoperative Tönnis grade, and alpha angle >65° were key risk factors in the radiographic progression of osteoarthritis. CONCLUSION Although the majority of patients (70%) undergoing hip arthroscopy for FAIS did not experience differences between operative and nonoperative hips in terms of the radiographic progression of osteoarthritis, the natural history may be favorably altered for 25% of patients whose Tönnis grade was better after undergoing arthroscopic correction. Modern hip arthroscopy indications and techniques represent a valid joint-preservation procedure conferring a relative risk reduction of 42% in the progression of osteoarthritis. Arthroscopy for mixed patterns of impingement and instability were the fastest to degenerate.
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Affiliation(s)
- Prem N Ramkumar
- Center for Hip Preservation, Hospital for Special Surgery, New York, New York, USA
- Long Beach Orthopaedic Institute, Long Beach, California, USA
| | - Reena J Olsen
- Center for Hip Preservation, Hospital for Special Surgery, New York, New York, USA
| | | | - Danyal H Nawabi
- Center for Hip Preservation, Hospital for Special Surgery, New York, New York, USA
| | - Bryan T Kelly
- Center for Hip Preservation, Hospital for Special Surgery, New York, New York, USA
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Takla A, Gunatilake K, Ma N, Moaveni A. Can intra-articular hip injections predict arthroscopy outcomes for femoroacetabular impingement syndrome? A systematic review. J Orthop 2024; 50:122-129. [PMID: 38214002 PMCID: PMC10776375 DOI: 10.1016/j.jor.2023.12.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2023] [Accepted: 12/08/2023] [Indexed: 01/13/2024] Open
Abstract
Background Femoroacetabular Impingement (FAI) syndrome represents a prevalent aetiology of hip discomfort observed among both adolescent and adult populations. It is initially managed conservatively with oral anti-inflammatories and physiotherapy; some patients proceed to receiving an intra-articular (IA) hip injection, but ultimately, the gold-standard treatment is hip arthroscopy. Study design Systematic Review. Purpose To systematically investigate the relationship between response to IA anaesthetic or steroid hip injections and arthroscopy outcomes for FAI syndrome. Methods A systematic search of PubMed, Medline, CINAHL, SCOPUS, and Cochrane was conducted in line with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines. Results Seven studies (Level II-IV) were identified that met our inclusion and exclusion criteria. These studies collectively included 637 patients, demonstrating an average age of 37.5 years (and a range of 14-72 years). Two of the seven studies reported a statistically significant positive correlation between response to IA injections and arthroscopy outcomes. The remaining five studies found that although a positive IA injection response increased the odds of a good outcome post arthroscopy (defined across various studies as a post-operative modified Harris Hip score of >70 points, >79 points or an improvement by 8 or more points), this correlation was not statistically significant. Conclusion IA hip injections can be a useful prognostic tool, though they are not a consistently reliable predictor of which patients will have good arthroscopic outcomes.
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Affiliation(s)
- Antony Takla
- The Alfred Hospital, Department of Orthopaedic Surgery, Australia
- Monash Bioethics Centre, Monash University, Australia
| | - Karin Gunatilake
- The Alfred Hospital, Department of Orthopaedic Surgery, Australia
| | - Norine Ma
- The Alfred Hospital, Department of Orthopaedic Surgery, Australia
| | - Ash Moaveni
- The Alfred Hospital, Department of Orthopaedic Surgery, Australia
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Kollmorgen R. Editorial Commentary: Physical Therapy Alone May Not Successfully Treat Patients With Hip Pain and Large α Angles or Decreased Femoral Anteversion Combined With Femoroacetabular Impingement Syndrome. Arthroscopy 2024; 40:777-779. [PMID: 38219139 DOI: 10.1016/j.arthro.2023.08.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2023] [Accepted: 08/14/2023] [Indexed: 01/15/2024]
Abstract
Understanding the relation between spinopelvic (lumbopelvic) tilt and femoracetabular impingement syndrome (FAIS) is complex, and determining the optimal patient parameters that lead to successful nonoperative management is vital. Physical therapy (PT) focusing on core and posterior chain strengthening is often successful. PT can change the posterior tilt of the pelvis by 5° to 10°, allowing increased range of motion (ROM) and decreased impingement of the hip. However, PT does not change cam anatomy. Thus, PT alone may not sufficiently increase ROM in patients with cam-type impingement and large α angles or limited femoral anteversion. Pelvic compensation may lead to successful nonoperative management of FAIS, but not in all patients. Large-cam, high-flexion athletes with chronic hip pain should try PT. Yet, while some patients with large cam lesions may improve without surgery if femoral version and/or pelvic tilt ROM can be increased, surgery should not be excessively delayed in patients with poor prognostic factors for nonoperative management.
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Saito M, Kobayashi N, Honda H, Kamono E, Yukizawa Y, Choe H, Ike H, Kumagai K, Inaba Y. Physical Therapy May Not Be Successful for Patients With Cam-Type Femoroacetabular Impingement Syndrome and May Result in Insufficient Hip Range of Motion When Femoral Anteversion Is Less Than 16° and α-Angle Is Greater Than 65°. Arthroscopy 2024; 40:766-776.e1. [PMID: 37479152 DOI: 10.1016/j.arthro.2023.07.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Revised: 06/23/2023] [Accepted: 07/01/2023] [Indexed: 07/23/2023]
Abstract
PURPOSE To identify factors associated with insufficient range of motion (ROM) improvement after the posterior pelvic tilt change in cam-type femoroacetabular impingement syndrome. METHODS Preoperative computed tomography images from 71 consecutive patients with femoroacetabular impingement syndrome treated with arthroscopic cam resection were evaluated. Using a dynamic computer simulation program, 3-dimensional models with a 10° posterior pelvic tilt from the supine functional pelvic plane (baseline) were created by computed tomography models. Patients were divided into 2 groups: those who experienced >10° (effective group) and ≤10° (ineffective group) improvements in internal rotation at 90° flexion after a 10° posterior pelvic tilt. Demographic characteristics; preoperative range of internal rotation at 90° flexion; and radiographic parameters, including Tönnis grade, lateral center-edge angle, acetabular roof obliquity angle, central acetabular anteversion, cranial acetabular anteversion, femoral anteversion, and α angle, were compared in the 2 groups. Univariate and multivariable logistic regression analyses were performed to evaluate factors associated with insufficient ROM improvement following a 10° posterior pelvic tilt. RESULTS The 71 patients included 58 men and 13 women, of mean age 41.4 ± 14.6 years. Posterior pelvic tilt was effective in 13 hips and ineffective in 58. Univariate analysis showed that preoperative range of internal rotation at 90°flexion, femoral anteversion, and α angle differed significantly in the 2 groups. Multivariable analysis showed that femoral anteversion <16° (odds ratio 7.4; 95% confidence interval 1.6-35; P = .012) and α angle >65° (odds ratio 6.7; 95% confidence interval 1.2-37; P = .027) were significant factors associated with insufficient ROM improvement after posterior pelvic tilt. CONCLUSIONS Physical therapy may not be successful for patients with cam-type femoroacetabular impingement syndrome and may result in insufficient hip ROM when femoral anteversion is less than 16° and α-angle is greater than 65°. CLINICAL RELEVANCE Patients with a prominent cam-type deformity and lower anterior femoral anteversion are at high risk of clinical failure following improvement in pelvic mobility by conservative treatment alone and are likely to benefit from surgery for cam deformity.
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Affiliation(s)
- Masayoshi Saito
- Department of Orthopaedic Surgery, Yokohama City University Medical Center, Yokohama, Japan; Department of Orthopaedic Surgery, Yokohama City University, Yokohama, Japan; Department of Orthopaedic Surgery, Hokusuikai Kinen Hospital, Mito, Ibaraki, Japan
| | - Naomi Kobayashi
- Department of Orthopaedic Surgery, Yokohama City University Medical Center, Yokohama, Japan.
| | - Hideki Honda
- Department of Orthopaedic Surgery, Yokohama City University Medical Center, Yokohama, Japan
| | - Emi Kamono
- Department of Orthopaedic Surgery, Yokohama City University Medical Center, Yokohama, Japan
| | - Yohei Yukizawa
- Department of Orthopaedic Surgery, Yokohama City University Medical Center, Yokohama, Japan
| | - Hyonmin Choe
- Department of Orthopaedic Surgery, Yokohama City University, Yokohama, Japan
| | - Hiroyuki Ike
- Department of Orthopaedic Surgery, Yokohama City University, Yokohama, Japan
| | - Ken Kumagai
- Department of Orthopaedic Surgery, Yokohama City University, Yokohama, Japan
| | - Yutaka Inaba
- Department of Orthopaedic Surgery, Yokohama City University, Yokohama, Japan
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Lim DP, Lazaro LE, Kyhos JF, Chau MM, Ladnier KJ, Nelson TJ, Eberlein SA, Banffy MB, Metzger MF. Contributions of the Abductor Muscles to Rotational and Distractive Stability of the Hip in a Biomechanical Cadaveric Model. Orthop J Sports Med 2024; 12:23259671241231984. [PMID: 38444567 PMCID: PMC10913509 DOI: 10.1177/23259671241231984] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Accepted: 08/23/2023] [Indexed: 03/07/2024] Open
Abstract
Background The gluteus minimus (GMin) and gluteus medius (GMed) are important dynamic stabilizers of the hip, but quantitative data on their biomechanical roles in stabilizing the hip are currently lacking. Purpose To (1) establish a reproducible biomechanical cadaveric model of the hip abductor complex and (2) characterize the effects of loading the GMin and GMed on extraneous femoral rotation and distraction. Study Design Controlled laboratory study. Methods A total of 10 hemipelvises were tested in 4 muscle loading states: (1) unloaded, (2) the GMin loaded, (3) the GMed loaded, and (4) both the GMin and GMed loaded. Muscle loads were applied via cables, pulleys, and weights attached to the tendons to replicate the anatomic lines of action. Specimens were tested under internal rotation; external rotation; and axial traction forces at 0°, 15°, 30°, 60°, and 90° of hip flexion. Results When loaded together, the GMin and GMed reduced internal rotation motion at all hip flexion angles (P < .05) except 60° and reduced external rotation motion at all hip flexion angles (P < .05) except 0°. Likewise, when both the GMin and GMed were loaded, femoral distraction was decreased at all angles of hip flexion (P < .05). Conclusion The results of this study demonstrated that the GMin and GMed provide stability against rotational torques and distractive forces and that the amount of contribution depends on the degree of hip flexion. Clinical Relevance Improved understanding of the roles of the GMin and GMed in preventing rotational and distractive instability of the hip will better guide treatment of hip pathologies and optimize nonoperative and operative therapies.
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Affiliation(s)
- Daniel P. Lim
- Kerlan-Jobe Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Lionel E. Lazaro
- Kerlan-Jobe Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Justin F. Kyhos
- Kerlan-Jobe Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Michael M. Chau
- Kerlan-Jobe Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Karen J. Ladnier
- Kerlan-Jobe Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Trevor J. Nelson
- Orthopaedic Biomechanics Laboratory, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Samuel A. Eberlein
- Orthopaedic Biomechanics Laboratory, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Michael B. Banffy
- Kerlan-Jobe Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Melodie F. Metzger
- Orthopaedic Biomechanics Laboratory, Cedars-Sinai Medical Center, Los Angeles, California, USA
- Department of Orthopaedic Surgery, Cedars-Sinai Medical Center, Los Angeles, California, USA
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Morris WZ, Loewen A, Ulman S, Johnson B, Sucato DJ, Podeszwa DA, Ellis HB. Comparison of Gait and Functional Outcomes Between Open and Arthroscopic Treatment of Adolescent and Young Adult Femoroacetabular Impingement. J Pediatr Orthop 2024; 44:22-27. [PMID: 37791636 DOI: 10.1097/bpo.0000000000002532] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/05/2023]
Abstract
BACKGROUND Management of femoroacetabular impingement (FAI) through an arthroscopic or surgical hip dislocation (SHD) approach has been shown to have similar clinical success and patient-reported outcomes. However, there are limited data comparing functional outcomes. The purpose of this study was to compare gait and functional outcomes of adolescent/young adult patients with FAI treated by either an arthroscopic or open SHD approach. METHODS We identified prospectively enrolled adolescent/young adult patients (≤20 years old) who underwent surgical treatment for FAI through an SHD or arthroscopic approach. Participants were evaluated in a movement science lab preoperatively and postoperatively (minimum 8 months postoperatively) with barefoot walking and a 30-second single-limb balance trial on the affected side. Participants also completed the Harris Hip Score at the same timepoints. Differences from preoperative to postoperative were determined using a paired-samples t test for each surgical technique, and differences between the SHD and arthroscopic groups were determined using an independent samples t test (α=0.05). RESULTS Fifty-five participants (42F, 16.2±1.4 y) were tested and grouped by surgical intervention. The SHD and arthroscopy groups consisted of 28 and 27 participants, respectively, with no significant difference between the SHD and arthroscopic cohorts in age (16.4±1.2 vs. 15.9±1.5 y, respectively, P =0.218) or sex distribution (78.6% vs. 74.1% females, respectively, P =0.75). Each group demonstrated significant postoperative improvement in Harris Hip Score (SHD: 64.8±16.4 to 81.8±17.8; arthroscopy: 57.0±16.7 to 84.7±19.7; preoperatively to postoperatively, respectively, both P <0.001). During gait, increased maximum hip flexion was observed following surgical intervention for the SHD group (32.3±5.7 vs. 36.1±5.2, P =0.003). No other clinically significant changes were detected in the SHD or arthroscopic groups preoperatively to postoperatively in trunk, pelvis, or hip kinematics in the coronal plane. During the balance task, neither cohort demonstrated markers of clinically significant abductor dysfunction. However, post operatively, the arthroscopy group was able to balance longer than the SHD group (18.8±7.8 vs. 14.2±2.7 s, respectively, P =0.008), although no differences were detected in trunk or pelvis position in the coronal plane during balance. CONCLUSIONS Both open SHD and arthroscopic treatment of FAI resulted in improved clinical outcomes with no clinically significant abductor dysfunction 1 year post operatively. However, further study is needed to determine whether more dynamic tasks can potentially elicit subtle differences between the groups. LEVELS OF EVIDENCE Level II-prospective study.
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Affiliation(s)
- William Z Morris
- Department of Orthopedics, Scottish Rite for Children, Dallas, TX
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12
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Sabatini FM, Cohen-Rosenblum A, Eason TB, Hannon CP, Mounce SD, Krueger CA, Gwathmey FW, Duncan ST, Landy DC. Incidence of Rapidly Progressive Osteoarthritis Following Intra-articular Hip Corticosteroid Injection: A Systematic Review and Meta-Analysis. Arthroplast Today 2023; 24:101242. [PMID: 37941925 PMCID: PMC10630590 DOI: 10.1016/j.artd.2023.101242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Revised: 09/05/2023] [Accepted: 09/14/2023] [Indexed: 11/10/2023] Open
Abstract
Background The American Academy of Orthopedic Surgery recommends intra-articular corticosteroid injections (CSIs) for managing hip osteoarthritis (OA) based on short-term, prospective studies. Recent retrospective studies have raised concerns that CSIs may lead to rapidly progressive OA (RPOA). We sought to systematically review the literature of CSIs for hip OA to estimate the incidence of RPOA. Methods MEDLINE, Embase, and Cochrane Library were searched to identify original research of hip OA patients receiving CSIs. Overall, 27 articles involving 5831 patients published from 1988 to 2022 were included. Study design, patient characteristics, CSI details, follow-up, and cases of RPOA were recorded. Studies were classified by their ability to detect RPOA based on follow-up. Random effects meta-analysis was used to calculate the incidence of RPOA for studies able to detect RPOA. Results The meta-analytic estimate of RPOA incidence was 6% (95% confidence interval, 3%-9%) based on 10 articles classified as able to detect RPOA. RPOA definitions varied from progression of OA within 6 months to the presence of destructive changes. These studies were subject to bias from excluding patients with missing post-CSI radiographs. The remaining 17 articles were classified as unable to detect RPOA, including all of the studies cited in the American Academy of Orthopedic Surgery recommendation. Conclusions The incidence of RPOA after CSIs remains unknown due to variation in definitions and follow-up. While RPOA following CSIs may be 6%, many cases are not severe, and this may reflect selection bias. Further research is needed to understand whether clinically significant RPOA is incident enough to limit CSI use.
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Affiliation(s)
- Franco M. Sabatini
- Department of Orthopaedic Surgery, University of Kentucky, Lexington, KY
| | | | - Travis B. Eason
- Department of Orthopaedic Surgery, University of Kentucky, Lexington, KY
| | - Charles P. Hannon
- Department of Orthopedic Surgery, Washington University, St. Louis, MO
| | - Samuel D. Mounce
- Department of Orthopaedic Surgery, University of Kentucky, Lexington, KY
| | - Chad A. Krueger
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute, Philadelphia, PA
| | - F. Winston Gwathmey
- Department of Orthopaedic Surgery, University of Virginia, Charlottesville, VA
| | - Stephen T. Duncan
- Department of Orthopaedic Surgery, University of Kentucky, Lexington, KY
| | - David C. Landy
- Department of Orthopaedic Surgery, University of Kentucky, Lexington, KY
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13
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Zanchi N, Safran MR, Herickhoff P. Return to Play After Femoroacetabular Impingement. Curr Rev Musculoskelet Med 2023; 16:587-597. [PMID: 37816998 PMCID: PMC10733256 DOI: 10.1007/s12178-023-09871-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/27/2023] [Indexed: 10/12/2023]
Abstract
PURPOSE OF REVIEW Femoroacetabular impingement (FAI) is a pathomechanical process whereby abnormal contact between proximal femur and acetabulum at end range of hip motion induces chondrolabral lesions within the hip joint. Surgery followed by a rehabilitation program or physical therapy with possible addition of an intra-articular corticosteroid injection are the two predominant treatments. The majority of authors recognize that a well-designed rehabilitation protocol is essential to achieve good outcomes with both nonoperative and surgical treatment. However, there is little evidence about what is the best rehabilitation protocol and most of the literature available is based on expert level opinion. This current review investigates the recent literature on nonoperative and postoperative rehabilitation protocol and return to play in FAI patients and describes our approach. RECENT FINDINGS Historically, rehabilitation protocols for treatment of FAI as well as return to play protocols were based on experts' opinion and low-level evidence studies. In order to improve standardization of protocols and to allow a better comparison in between different protocols, different authors have created standardized rehabilitation protocols with consensus building methods comparing them with other treatment options in high-level evidence trials (FASHIoN trial, etc.). Despite the excellent results reported after nonoperative and post-surgical rehabilitation, and the high RTP rate after FAI treatment, there is a significant variability in between protocols. Further high-level evidence studies are necessary in order to establish a gold standard in rehabilitation and RTP protocols.
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Affiliation(s)
- Nicolò Zanchi
- Orthopaedic Surgery, Penn State Health Milton S. Hershey Medical Center, 1850 E Park Ave, State College, PA, USA.
| | - Marc R Safran
- Department of Orthopaedic Surgery, Stanford University, Redwood City, CA, USA
| | - Paul Herickhoff
- Orthopaedic Surgery, Penn State Health Milton S. Hershey Medical Center, 1850 E Park Ave, State College, PA, USA
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14
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Pasculli RM, Callahan EA, Wu J, Edralin N, Berrigan WA. Non-operative Management and Outcomes of Femoroacetabular Impingement Syndrome. Curr Rev Musculoskelet Med 2023; 16:501-513. [PMID: 37650998 PMCID: PMC10587039 DOI: 10.1007/s12178-023-09863-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/07/2023] [Indexed: 09/01/2023]
Abstract
PURPOSE To serve as a guide for non-operative physicians in the management of femoroacetabular impingement syndrome and provide an algorithm as to when to refer patients for potential surgical management. RECENT FINDINGS Supervised physical therapy programs that focus on active strengthening and core strengthening are more effective than unsupervised, passive, and non-core-focused programs. There is promising evidence for the use of intra-articular hyaluronic acid and PRP as adjunct treatment options. Recent systematic reviews and meta-analyses have found that in young active patients, hip arthroscopy demonstrates improved short-term outcomes over physical therapy. The decision for the management of FAIS is complex and should be specific to each patient. Consideration of the patient's age, timing to return to sport, longevity of treatment, hip morphology, and degree of cartilage degeneration is required to make an informed decision in the treatment of these patients.
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Affiliation(s)
- Rosa M. Pasculli
- Department of Orthopaedics, Emory University School of Medicine, Atlanta, GA USA
| | - Elizabeth A. Callahan
- Department of Physical Medicine and Rehabilitation, New York University, New York, NY USA
| | - James Wu
- University of California Berkeley, Berkeley, CA USA
| | - Niam Edralin
- University of California Berkeley, Berkeley, CA USA
| | - William A. Berrigan
- Department of Orthopaedics, University of California San Francisco, 1500 Owens Street, San Francisco, CA 94158 USA
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15
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Kuhn AW, Clohisy JC, Troyer SC, Cheng AL, Hillen TJ, Pascual-Garrido C, Tatman J, Bloom N, Schoenecker PL, Nepple JJ. Team Approach: Hip Preservation Surgery. JBJS Rev 2023; 11:01874474-202310000-00001. [PMID: 37793005 DOI: 10.2106/jbjs.rvw.23.00041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/06/2023]
Abstract
The evaluation and treatment of adolescents and young adults with hip pain has seen tremendous growth over the past 20 years. Labral tears are well established as a common cause of hip pain but often occur because of underlying bony abnormalities. Femoroacetabular impingement (FAI) and acetabular dysplasia are now well-established causes of hip osteoarthritis and are increasingly treated in the prearthritic stage in hopes of improving symptoms and prolonging the longevity of the native hip. Beyond FAI and acetabular dysplasia, this patient population can present with a complex and variable group of underlying conditions that need to be taken into account. Expertise in the conservative management of this population, including physical therapy, is valuable to maximize the success. Preoperative, surgical, and postoperative decision-making and care in this population is complex and evolving. A comprehensive, multidisciplinary approach to the care of this patient population has been used for over 20 years by our institution with great success. The purpose of this article is to review the "team-based approach" necessary for successful management of the spectrum of adolescent and young adult hip disorders.
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Affiliation(s)
- Andrew W Kuhn
- Department of Orthopaedic Surgery, Washington University in St. Louis, St. Louis, Missouri
| | - John C Clohisy
- Department of Orthopaedic Surgery, Washington University in St. Louis, St. Louis, Missouri
| | | | - Abby L Cheng
- Department of Orthopaedic Surgery, Washington University in St. Louis, St. Louis, Missouri
| | - Travis J Hillen
- Department of Radiological Science, Washington University in St. Louis, St. Louis, Missouri
| | | | - Justin Tatman
- Department of Orthopaedic Surgery, Washington University in St. Louis, St. Louis, Missouri
| | - Nancy Bloom
- Program in Physical Therapy, Washington University School of Medicine, St. Louis, Missouri
| | - Perry L Schoenecker
- Department of Orthopaedic Surgery, Washington University in St. Louis, St. Louis, Missouri
| | - Jeffrey J Nepple
- Department of Orthopaedic Surgery, Washington University in St. Louis, St. Louis, Missouri
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16
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Hanish S, Muhammed M, Kelly S, DeFroda S. Postoperative Rehabilitation for Arthroscopic Management of Femoroacetabular Impingement Syndrome: a Contemporary Review. Curr Rev Musculoskelet Med 2023; 16:381-391. [PMID: 37310616 PMCID: PMC10427582 DOI: 10.1007/s12178-023-09850-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/31/2023] [Indexed: 06/14/2023]
Abstract
PURPOSE OF REVIEW Femoroacetabular impingement syndrome (FAIS) is a common cause of hip pain that may potentially lead to osteoarthritis. Operative management of FAIS seeks to arthroscopically reshape the abnormal hip morphology and repair the labrum. For rehabilitation following operative management, a structured physical therapy program is unanimously recommended for the patient to return to their previous level of physical activity. Yet, despite this unanimous recommendation, significant heterogeneity exists among the current recommendations for postoperative physical therapy programs. RECENT FINDINGS A four-phase postoperative physical therapy protocol is favored among current literature, with each phase being comprised of its own goals, restrictions, precautions, and rehabilitation techniques. Phase 1 aims to protect the integrity of the surgically repaired tissues, reduce pain and inflammation, and regain ~ 80% of full ROM. Phase 2 guides a smooth transition to full weightbearing, so the patient may regain functional independence. Phase 3 helps the patient become recreationally asymptomatic and restores muscular strength and endurance. Finally, phase 4 culminates in the pain-free return to competitive sports or recreational activity. At this time, there exists no single, unanimously agreed upon postoperative physical therapy protocol. Among the current recommendations, variation exists regarding specific timelines, restrictions, precautions, exercises, and techniques throughout the four phases. It is imperative to reduce ambiguity in current recommendations and more specifically define postoperative physical therapy following operative management of FAIS to more expeditiously return patients to functional independence and physical activity.
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Affiliation(s)
- Stefan Hanish
- Department of Orthopaedic Surgery, University of Missouri School of Medicine, Columbia, MO, USA
| | - Maaz Muhammed
- Department of Orthopaedic Surgery, University of Missouri School of Medicine, Columbia, MO, USA
| | - Shayne Kelly
- Department of Orthopaedic Surgery, University of Missouri School of Medicine, Columbia, MO, USA
| | - Steven DeFroda
- Department of Orthopaedic Surgery, University of Missouri School of Medicine, Columbia, MO, USA.
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Pruneski JA, Chan JJ, Wang KC, Matheney T, Bharam S. Acetabular Rim Disorders: Epidemiology, Etiology, Management, and Outcomes. JBJS Rev 2023; 11:01874474-202308000-00005. [PMID: 37549243 DOI: 10.2106/jbjs.rvw.23.00058] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/09/2023]
Abstract
» Anatomic disorders of the acetabular rim are a common, correctable source of hip pain in younger patients.» Some common conditions of involving abnormal acetabular rim morphology include developmental dysplasia of the hip, pincer-type femoroacetabular impingement, acetabular protrusion, and acetabular retroversion.» Treatment option for these conditions were historically limited to open osteotomy and osteoplasty procedures; however, there is increasing use of arthroscopic intervention for these patients.» Arthroscopic intervention has demonstrated short-term success in a variety of focal acetabular rim disorders; however, further research is needed to determine the long-term outcomes of these procedures and their utility in more global pathology.
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Affiliation(s)
- James A Pruneski
- Tripler Army Medical Center, Honolulu, Hawaii
- Boston Children's Hospital, Boston, Massachusetts
| | - Jimmy J Chan
- Boston Children's Hospital, Boston, Massachusetts
- Mount Sinai Health System, New York, New York
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18
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Enseki KR, Bloom NJ, Harris-Hayes M, Cibulka MT, Disantis A, Di Stasi S, Malloy P, Clohisy JC, Martin RL. Hip Pain and Movement Dysfunction Associated With Nonarthritic Hip Joint Pain: A Revision. J Orthop Sports Phys Ther 2023; 53:CPG1-CPG70. [PMID: 37383013 DOI: 10.2519/jospt.2023.0302] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/30/2023]
Abstract
The Academy of Orthopaedic Physical Therapy (AOPT), formerly the Orthopaedic Section of the American Physical Therapy Association (APTA), has an ongoing effort to create evidence-based practice guidelines for orthopaedic physical therapy management of patients with musculoskeletal impairments described in the World Health Organization's International Classification of Functioning, Disability, and Health (ICF). This is an update to the 2014 Clinical Practice Guideline (CPG) for Hip Pain and Movement Dysfunction Associated with Nonarthritic Hip Joint Pain. The goals of the revision were to provide a concise summary of the contemporary evidence since publication of the original guideline and to develop new recommendations or revise previously published recommendations to support evidence-based practice. This current CPG covers pathoanatomical features, clinical course, prognosis, diagnosis, examination, and physical therapy interventions in the management of nonarthritic hip joint pain. J Orthop Sports Phys Ther 2023;53(7):CPG1-CPG70. doi:10.2519/jospt.2023.0302.
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van den Hoek CW, Wolterbeek N, Kaas L. Patient characteristics cannot predict the long-term effect of an intra-articular bupivacaine and corticosteroid injection in patients with femoroacetabular impingement: A retrospective cohort study. J Clin Orthop Trauma 2023; 41:102174. [PMID: 37483913 PMCID: PMC10362536 DOI: 10.1016/j.jcot.2023.102174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Accepted: 05/28/2023] [Indexed: 07/25/2023] Open
Abstract
Background To evaluate predictors for effect of an intra-articular (IA) bupivacaine and corticosteroid injection in patients with femoroacetabular impingement syndrome (FAIS). Methods All patients between 18 and 50 years old with FAIS who received an intra-articular (IA) bupivacaine and corticosteroid injection between 2016 and 2019 were eligible for this retrospective study. Two groups were made, the non-arthroscopy group (patients for whom conservative treatment with physiotherapy and an IA bupivacaine and corticosteroid injection was sufficient) and the arthroscopy group (patients who needed an arthroscopy because conservative treatment and an IA bupivacaine and corticosteroid injection failed). Multiple regression analysis was performed to analyse the effect of the IA corticosteroid injection and to predict arthroscopic intervention based on sex, age, body mass index, duration of complaints, alpha angle and abnormal bone morphology. Results In total 103 patients were included; 46 in the arthroscopy group and 57 in the non-arthroscopy group. The groups had similar baseline characteristics. A total of 37 (36%) patients had an effect of 3 months or longer from the IA corticosteroid injection; 31 (54%) were patients in the non-arthroscopy group versus 6 (13%) patients in the arthroscopy group (P < 0.001). Male sex seems to have an negative influence on the duration of the effect of the injection. None of the variables could significantly predict if a patient would undergo arthroscopic intervention (F(7,103) = 8.54, p = 0.3, R2 = 0.11). The effect of the IA injection could not be predicted (p = 0.1; R2 = 0.13). Conclusion There are no patient characteristics that predict who would and who would not benefit from the IA bupivacaine and corticosteroid injection in patients with FAIS and who would need an arthroscopic intervention within 1 year after the injection. Only male sex seems to have an negative influence on the duration of the effect of the injection.
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Affiliation(s)
- Catharina W. van den Hoek
- Dept. Orthopedic Surgery, St. Antonius Hospital, Koekoekslaan 1, 3435 CM, Nieuwegein, the Netherlands
| | - Nienke Wolterbeek
- Dept. Orthopedic Surgery, St. Antonius Hospital, Koekoekslaan 1, 3435 CM, Nieuwegein, the Netherlands
| | - Laurens Kaas
- Dept. Orthopedic Surgery, St. Antonius Hospital, Koekoekslaan 1, 3435 CM, Nieuwegein, the Netherlands
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Leary SM, Westermann RW. Arthroscopic Decompression of the Anterior Inferior Iliac Spine. JBJS Essent Surg Tech 2023; 13:e22.00019. [PMID: 38274146 PMCID: PMC10807891 DOI: 10.2106/jbjs.st.22.00019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2024] Open
Abstract
Background Pathologic contact between the femoral neck and anterior inferior iliac spine (AIIS or subspine) often occurs concomitantly with femoroacetabular impingement, contributing to hip pain and dysfunction1-4. We perform arthroscopic AIIS decompression to alleviate this source of extra-articular impingement and eliminate a potential cause of persistent pain following primary hip arthroscopy5-7. Description After identifying abnormal AIIS morphology on preoperative false-profile radiographs and/or 3D computed tomography, we utilize a beaver blade to make a small incision in the proximal capsule and rectus femoris tendon. This peri-capsulotomy window grants access to the subspine region. We then shuttle an arthroscopic burr into place within this window and begin debriding the subspine deformity under direct visualization. Fluoroscopy is utilized intraoperatively to ensure adequate resection, using intraoperative false-profile views achieved by canting the C-arm approximately 40°. Resection is considered adequate when the AIIS deformity is no longer readily apparent on false-profile views and when intraoperative range-of-motion testing confirms no further impingement with hip hyperflexion. Alternatives Femoroacetabular impingement can be treated nonoperatively with use of physical therapy and activity modification8; however, outcomes following nonoperative treatment are inferior to those following hip arthroscopy, according to various studies9-12. There are no known alternative treatments specific to subspine impingement. Rationale As patients with subspine deformities progress through hip flexion, the femoral neck collides with the AIIS, limiting range of motion. As such, subspine deformities have been shown to be more common in dancers and other high-flexion athletes13,14. Additionally, studies have demonstrated that low femoral version of <5° is associated with increased contact between the distal femoral neck and the AIIS. This pathologic contact can occur even in the absence of an obvious subspine deformity15. In both of these patient populations, surgeons should have a high suspicion for subspine impingement, and a subspine decompression should be performed during hip arthroscopy in order to maximize patient outcomes. Expected Outcomes This is a safe procedure that, if performed when indicated, can improve outcomes following primary hip arthroscopy. A recent systematic review found a pooled complication risk of 1.1%, a pooled revision risk of 1.0%, and significant postoperative improvements in patient-reported outcome measures16. Important Tips Suspect subspine impingement in high-flexion athletes and patients with low femoral version, even in the absence of an obvious deformity.Ensure adequate visualization of the entire subspine deformity by creating a pericapsular window.Confirm thorough resection with use of fluoroscopic imaging intraoperatively, including false-profile views demonstrating absent subspine deformity. Acronyms and Abbreviations FAI = femoroacetabular impingementAP = anteroposterior, refers to the technique used to obtain one of the pelvic radiographs3D CT = three-dimensional computed tomographyLCEA = lateral center-edge angle, a measurement used to quantify severity of hip dysplasiaOR = operating roomAlpha = alpha angle, a measurement used to measure femoral head-neck offset and assess the severity of a cam deformityIc = iliocapsularisRFd = direct head of rectus femorisRFr = reflected head of rectus femorisCap = hip capsuleGMi = gluteus minimusmHHS = modified Harris Hip ScoreHOS-ADL = Hip Outcome Score - Activities of Daily LivingHOS-SSS = Hip Outcome Score - Sports Specific Subscale.
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Ross BJ, Lupica GM, Dymock ZR, Miskimin C, Mulcahey MK. Sex-related differences in hip and groin injuries in adult runners: a systematic review. PHYSICIAN SPORTSMED 2023; 51:107-120. [PMID: 34905425 DOI: 10.1080/00913847.2021.2016355] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
OBJECTIVES Hip/groin running-related injuries (RRIs) are relatively uncommon. It is unclear if runners of either sex are disproportionately affected. Our objective was to systematically review differences in hip/groin RRIs between males and females. DATA SOURCES A structured and comprehensive search of four medical literature databases was performed (PubMed, Embase, Ovid Medline, and CINAHL). Terms searched were as follows: risk, epidemiology, hip injury, groin injury, overuse injury, running, sprinting, and track and field. STUDY SELECTION Studies reporting sex-specific data on hip/groin RRIs in adult runners were included. Data was extracted and reviewed independently by two authors. STUDY APPRAISAL AND DATA SYNTHESIS Sex-specific injury rates, risk factors, and return to sport (RTS) following hip/groin RRI were extracted. Risk of bias was assessed using the Joanna-Briggs Institute Critical Appraisal Tool. RESULTS Ten studies with 7,353 total runners were included: 2,315 (47%) males and 2,559 (53%) females. The mean age of the included runners was 37.3 ± 8.9 years and the mean weekly running distance was 10.4 ± 8.4 km. Hip/groin injuries comprised 10.1% (491/4,874) of total RRIs, including 6.3% of RRIs sustained by males and 11.0% by females. Three studies reported significantly higher rates of hip/groin RRIs in female runners. One study reported significantly higher rates of gluteus medius and adductor RRIs for females and males, respectively. One study identified female sex as an independent risk factor for hip/groin RRIs. Three studies reported on RTS after hip/groin RRIs: the pooled RTS rate was 81.4% (57/70) at 1 to 368 days after injury. LIMITATIONS Data was pooled when possible; however, there was considerable clinical, methodological, and statistical heterogeneity across studies. CONCLUSIONS Hip/groin RRIs comprise a greater percentage of total injuries among injured female runners relative to males. Females may be at a higher risk for sustaining hip/groin RRIs though more research on risk factors and RTS is needed.
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Affiliation(s)
| | | | - Zakari R Dymock
- Department of Physical Medicine & Rehabilitation, University of Kentucky College of Medicine, Lexington
| | - Cadence Miskimin
- Department of Orthopaedic Surgery, Tulane University School of Medicine, New Orleans
| | - Mary K Mulcahey
- Department of Orthopaedic Surgery, Tulane University School of Medicine, New Orleans
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22
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Ebert JR, Raymond AC, Aujla RS, D'Alessandro P. The Effect of a Formal Nonoperative Management Program Combining a Hip Injection With Structured Adjunctive Exercise Rehabilitation in Patients With Symptomatic Femoroacetabular Impingement Syndrome. Am J Sports Med 2023; 51:694-706. [PMID: 36752689 DOI: 10.1177/03635465221148744] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/09/2023]
Abstract
BACKGROUND Although the initial treatment recommendations for femoroacetabular impingement syndrome (FAIS) may include nonsurgical therapies such as injections and rehabilitation, many patients undergo isolated injections or a rudimentary exercise regimen. PURPOSE To investigate the benefit of an intra-articular hip injection and concomitant structured exercise rehabilitation program in patients with symptomatic FAIS ≥6 months. STUDY DESIGN Case series; Level of evidence, 4. METHODS For this study we recruited 49 patients with a mean age of 32.8 years (range, 16-56 years) and symptoms ≥6 months (range, 6-250 months) associated with FAIS, as confirmed via magnetic resonance imaging and radiography. After a guided intra-articular injection of corticosteroid and local anesthetic, patients underwent a structured 12-week rehabilitation program. Patients were assessed before and after injection (8 weeks and 4, 6, 12, and 24 months) with a range of patient-reported outcome measures (PROMs), including the 33-item International Hip Outcome Tool, Hip Outcome Score, modified Harris Hip Score, the Tegner Activity Score, a visual analog scale assessing the frequency and severity of hip pain, and a Global Rating of Change scale. Range of motion, peak isometric hip strength, and hop tests were assessed. Absolute scores and limb symmetry indices were calculated. The percentage of patients transitioning toward surgery over the period was evaluated. RESULTS Of the 44 patients who underwent the injection and completed the initial 8-week rehabilitation component, 14 (31.8%) progressed toward surgical intervention over the 24-month postinjection period owing to dissatisfaction and/or symptom recurrence. Patients who progressed toward surgery, as compared with those who did not, reported significantly worse (P < .05) PROMs presurgery and more pain within the first 4 weeks after injection. In the nonoperative cohort, a significant improvement (P < .05) in all PROMs was observed, with 93% of these patients satisfied overall. The Global Rating of Change did not improve, although this was measured only after the injection, reflecting no further significant perceived global change from 8 weeks to 24 months. A significant increase (P < .05) in all hip range of motion and most isometric strength measures was observed at 8 weeks after injection, with these improvements largely sustained until 24 months. Bilateral improvements in hop capacity were observed, with hop test LSIs significantly improving for the single (p = 0.009), triple (p = 0.029) and triple crossover (p = 0.005) hop tests for distance. CONCLUSION Although 32% of patients progressed toward surgery, significant improvement in hip pain, symptoms, and physical function was observed in the majority of patients with symptomatic FAIS as a result of a targeted nonoperative management pathway consisting of an intra-articular injection and a structured exercise program.
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Affiliation(s)
- Jay R Ebert
- School of Human Sciences (Exercise and Sport Science), University of Western Australia, Crawley, Australia
- HFRC Rehabilitation Clinic, Nedlands, Australia
- Orthopaedic Research Foundation of Western Australia, Bethesda Hospital, Claremont, Australia
| | | | | | - Peter D'Alessandro
- Orthopaedic Research Foundation of Western Australia, Bethesda Hospital, Claremont, Australia
- Coastal Orthopaedics, Bethesda Hospital, Claremont, Australia
- Fiona Stanley and Fremantle Hospitals Group, South Metropolitan Health Service, Murdoch, Australia
- School of Surgery, University of Western Australia, Crawley, Australia
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23
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Ramkumar PN, Berrier AS, Helm JM, Koolmees DS, Pareek A, Krych AJ, Makhni EC, Harris JD, Nwachukwu BU. Evaluating the Need for Preoperative MRI Before Primary Hip Arthroscopy in Patients 40 Years and Younger With Femoroacetabular Impingement Syndrome: A Multicenter Comparative Analysis. Orthop J Sports Med 2023; 11:23259671221144776. [PMID: 36655021 PMCID: PMC9841845 DOI: 10.1177/23259671221144776] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2022] [Accepted: 09/26/2022] [Indexed: 01/13/2023] Open
Abstract
Background Routine hip magnetic resonance imaging (MRI) before arthroscopy for patients with femoroacetabular impingement syndrome (FAIS) offers questionable clinical benefit, delays surgery, and wastes resources. Purpose To assess the clinical utility of preoperative hip MRI for patients aged ≤40 years who were undergoing primary hip arthroscopy and who had a history, physical examination findings, and radiographs concordant with FAIS. Study Design Cohort study; Level of evidence, 3. Methods Included were 1391 patients (mean age, 25.8 years; 63% female; mean body mass index, 25.6) who underwent hip arthroscopy between August 2015 and December 2021 by 1 of 4 fellowship-trained hip surgeons from 4 referral centers. Inclusion criteria were FAIS, primary surgery, and age ≤40 years. Exclusion criteria were MRI contraindication, reattempt of nonoperative management, and concomitant periacetabular osteotomy. Patients were stratified into those who were evaluated with preoperative MRI versus those without MRI. Those without MRI received an MRI before surgery without deviation from the established surgical plan. All preoperative MRI scans were compared with the office evaluation and intraoperative findings to assess agreement. Time from office to arthroscopy and/or MRI was recorded. MRI costs were calculated. Results Of the study patients, 322 were not evaluated with MRI and 1069 were. MRI did not alter surgical or interoperative plans. Both groups had MRI findings demonstrating anterosuperior labral tears treated intraoperatively (99.8% repair, 0.2% debridement, and 0% reconstruction). Compared with patients who were evaluated with MRI and waited 63.0 ± 34.6 days, patients who were not evaluated with MRI underwent surgery 6.5 ± 18.7 days after preoperative MRI. MRI delayed surgery by 24.0 ± 5.3 days and cost a mean $2262 per patient. Conclusion Preoperative MRI did not alter indications for primary hip arthroscopy in patients aged ≤40 years with a history, physical examination findings, and radiographs concordant with FAIS. Rather, MRI delayed surgery and wasted resources. Routine hip MRI acquisition for the younger population with primary FAIS with a typical presentation should be challenged.
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Affiliation(s)
- Prem N. Ramkumar
- Department of Orthopaedic Surgery, Brigham & Women’s Hospital, Boston, Massachusetts, USA
- Center for Hip Preservation, Hospital for Special Surgery, New York, New York, USA
- Prem N. Ramkumar, MD, MBA, Department of Orthopaedic Surgery, Brigham & Women’s Hospital, 75 Francis Street, Boston, MA 02115, USA () (Twitter: @prem_ramkumar)
| | - Ava S. Berrier
- Department of Orthopaedic Surgery, Baylor College of Medicine, Houston, Texas, USA
| | - J. Matthew Helm
- Department of Orthopaedic Surgery, McGovern Medical School University of Texas Health Science Center, Houston, Texas, USA
| | - Dylan S. Koolmees
- Department of Orthopaedic Surgery, Henry Ford Hospital, Detroit, Michigan, USA
| | - Ayoosh Pareek
- Department of Orthopedic Surgery & Sports Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Aaron J. Krych
- Department of Orthopedic Surgery & Sports Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Eric C. Makhni
- Department of Orthopaedic Surgery, Henry Ford Hospital, Detroit, Michigan, USA
| | - Joshua D. Harris
- Houston Methodist Orthopedics & Sports Medicine, Houston, Texas, USA
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24
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Andronic O, Claydon-Mueller LS, Cubberley R, Karczewski D, Lu V, Khanduja V. No evidence exists on outcomes of non-operative management in patients with femoroacetabular impingement and concomitant Tönnis Grade 2 or more hip osteoarthritis: a scoping review. Knee Surg Sports Traumatol Arthrosc 2022; 31:2103-2122. [PMID: 36484811 PMCID: PMC10183431 DOI: 10.1007/s00167-022-07274-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Accepted: 12/01/2022] [Indexed: 12/14/2022]
Abstract
PURPOSE The purpose of this scoping review was to assess the outcomes of all the non-operative modalities of management for femoroacetabular impingement (FAI) and concomitant osteoarthritis (OA) Tönnis Grade 2 or more. METHODS A systematic search of PubMed was performed from inception to December 1st 2021 for literature on outcomes of non-operative management strategies for young adults with symptomatic FAI using the PRISMA Extension for Scoping Reviews guidelines. Cohorts investigating FAI and concomitant hip OA Tönnis Grade 2 or more were considered eligible. Studies not written in English or German, below level 4 evidence, and reviews were excluded. A secondary analysis for FAI without OA stratification was conducted after the initial screening to allow identification of available non-operative interventions. RESULTS No study reported outcomes separately for non-operative management of FAI with Tönnis Grade 2 OA or more and as such, did not fulfil the inclusion criteria. A secondary analysis included 24 studies that reported on outcomes for non-operative interventions for FAI irrespective of the degree of degeneration. Three studies investigated the efficacy of hyaluronic acid injection, 5 reports investigated corticosteroid injections, 2 studies evaluated the outcomes of hip bracing and 16 studies included a physiotherapy programme. Associations between the aforementioned interventions were analysed. There is level I evidence supporting the efficacy of activity modification and hip-specific physiotherapy for FAI and mild OA. Core-strengthening exercises are prevalent amongst successful regimens in the literature. Contradictory evidence questions the efficacy of hip bracing even for short-term outcomes. Corticosteroid injections have mostly failed in intention-to treat analyses but may be valuable in delaying the need for surgery; further studies are warranted. Reports on outcomes following hyaluronic acid injections are contradictory. CONCLUSION No evidence exists on outcomes following non-operative management of FAI with concomitant Tönnis Grade 2 or more OA of the hip. Further studies are required and should explore the non-operative interventions that were employed for FAI and milder OA. There is strong evidence for a hip-specific physiotherapy program including activity modification and core strengthening exercises. Adjunct interventions such as corticosteroid injections and NSAID consumption may be valuable in delaying the need for surgery. LEVEL OF EVIDENCE Level IV.
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Affiliation(s)
- Octavian Andronic
- Department of Orthopaedics, Balgrist University Hospital, University of Zürich, Forchstrasse, 340, 8008, Zurich, Switzerland. .,Medical Technology Research Centre, Anglia Ruskin University, Bishop Hall Lane, Chelmsford, CM1 1SQ, UK. .,Young Adult Hip Service, Department of Trauma and Orthopaedics, Adden-brooke's Cambridge University Hospital, Box 37, Hills Road, Cambridge, CB2 0QQ, UK.
| | | | - Rachael Cubberley
- Medical Technology Research Centre, Anglia Ruskin University, Bishop Hall Lane, Chelmsford, CM1 1SQ, UK
| | - Daniel Karczewski
- Department of Trauma and Orthopaedics, Center for Musculoskeletal Surgery, Charitè University Medicine Berlin, Charitéplatz 1, 10117, Berlin, Germany
| | - Victor Lu
- School of Clinical Medicine, University of Cambridge, Cambridge, CB2 0SP, UK
| | - Vikas Khanduja
- Medical Technology Research Centre, Anglia Ruskin University, Bishop Hall Lane, Chelmsford, CM1 1SQ, UK.,Young Adult Hip Service, Department of Trauma and Orthopaedics, Adden-brooke's Cambridge University Hospital, Box 37, Hills Road, Cambridge, CB2 0QQ, UK
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25
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Maldonado DR, Kufta AY, Krych AJ, Levy BA, Okoroha KR, Gonzalez-Carta K, Domb BG. Primary Hip Arthroscopy for Femoroacetabular Impingement Syndrome in Adolescents Improves Outcomes and Clinical Benefit Achievement Rates at Short-Term Follow-Up. A Multicenter Analysis. Arthroscopy 2022; 39:1211-1219. [PMID: 36572612 DOI: 10.1016/j.arthro.2022.11.020] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Revised: 09/01/2022] [Accepted: 11/14/2022] [Indexed: 12/13/2022]
Abstract
PURPOSE To report minimum 2-year follow-up patient-reported outcome scores (PROs) and rates of achieving the minimal clinically important difference (MCID), the patient-acceptable symptomatic state (PASS), and the maximal outcome improvement (MOI) on adolescents following primary hip arthroscopy for femoroacetabular impingement syndrome (FAIS). Second, to determine risk factors for revision surgery. METHODS Prospectively collected data from two high-volume hip arthroscopy centers were retrospectively reviewed on adolescents (≤19 years old) who underwent primary hip arthroscopy between November 2008 and February 2019. Adolescents with a minimum 2-year follow-up for the modified Harris Hip Score (mHHS), Non-Arthritic Hip Score (NAHS), Hip Outcome Score-Sports Specific Subscale (HOS-SSS), International Hip Outcome Tool-12 (iHOT-12), and visual analog scale (VAS) for pain were included regardless of their growth plate status. Exclusion criteria were Tönnis grade >1, lateral center edge-angle <18°, and previous ipsilateral hip surgery or conditions. Preoperative and postoperative radiographic data, MCID, PASS, MOI, secondary surgeries, and complications were reported. A multivariable survival analysis for risk factors for secondary surgery was conducted. RESULTS A total of 287 hips (249 patients) were included (74.9% females). The mean values for age, body mass index, and follow-up were 16.3 ± 1.3 years, 22.3 ± 3.5, and 26.6 ± 9.4 months, respectively. Further, 88.9% underwent labral repair, 81.5% femoroplasty, and 85.4% capsular closure. Improvement for all PROs was reported (P < .001) with high patient satisfaction (8.8 ± 1.5). Achievement for the MCID was 71.7%, 83.0%, 68.1%, and 79.5% for the mHHS, NAHS, HOS-SSS, and iHOT-12, respectively. Achievement for the PASS was 68.3% for the mHHS and 73.2% for the NAHS. The MOI for mHHS, NAHS, and VAS was 58.3%, 77.0%, and 59.6%, respectively. Rates of revision hip arthroscopy, cam recurrence, and heterotopic ossification were 5.8%, 1.7%, and 5.5%, respectively. Acetabular retroversion was found to be a risk factor for revision surgery (P = .03). CONCLUSION The results of this multi-center study demonstrated that adolescents who underwent primary hip arthroscopy for FAIS reported significant improvement in all PROs, with satisfactory achievement rates for the MCID, PASS, MOI, and high patient satisfaction at a minimum 2-year follow-up. LEVEL OF EVIDENCE IV, retrospective multicenter study.
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Affiliation(s)
- David R Maldonado
- American Hip Institute Research Foundation, Chicago, Illinois, USA; Department of Orthopaedic Surgery, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Allison Y Kufta
- American Hip Institute Research Foundation, Chicago, Illinois, USA
| | - Aaron J Krych
- Department of Orthopedic Surgery and Sports Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Bruce A Levy
- Department of Orthopedic Surgery and Sports Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Kelechi R Okoroha
- Department of Orthopedic Surgery and Sports Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Karina Gonzalez-Carta
- Department of Orthopedic Surgery and Sports Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Benjamin G Domb
- American Hip Institute Research Foundation, Chicago, Illinois, USA; American Hip Institute, Chicago, Illinois, USA.
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26
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Horner NS, Rice MW, Sivasundaram L, Alter T, Ephron CG, Nho SJ. Staged Bilateral Hip Arthroscopy for Femoroacetabular Impingement Syndrome: Index Surgery Patient Reported Outcome Measures Predict Contralateral Surgery Results at 2 Years. Arthroscopy 2022; 39:1175-1182.e1. [PMID: 36653274 DOI: 10.1016/j.arthro.2022.10.048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Revised: 09/25/2022] [Accepted: 10/12/2022] [Indexed: 12/14/2022]
Abstract
PURPOSE To determine whether (1) patient-reported outcome (PRO) scores after index hip arthroscopy correlate with PRO scores for the contralateral hip in patients undergoing staged bilateral hip arthroscopy and (2) patients who achieved minimal clinically important difference (MCID) or patient-acceptable symptom state (PASS) for the index hip were more likely to achieve MCID or PASS for the contralateral hip. METHODS Patients who underwent staged bilateral hip arthroscopy for femoroacetabular impingement syndrome were retrospectively reviewed. PRO scores were prospectively collected at preoperative and 1- and 2-year timepoints. Odds ratios for achievement of MCID and PASS for the contralateral hip given achievement for the index hip were calculated. Improvements from before surgery to 2 years after surgery were correlated between both hips. RESULTS A total of 143 patients (286 hips) were included in the final analysis. Average time between surgeries was 8.5 months (range, 0.7-57.2). Both hips demonstrated significant improvement (P < .05 for all) in all PROs at 2 years. Achievement of MCID in Hip Outcome Score Activities of Daily Living (HOS-ADL) at the 1-year timepoint for the index hip was predictive of achievement of MCID in HOS-ADL at 2 years for the contralateral hip. Achievement of PASS in all PROs at the 1-year timepoint for the index hip were predictive of achievement of PASS in the equivalent outcome score at the 2-year mark for the contralateral hip. Achievement of MCID or PASS at the 2-year timepoint for the index hip was predictive of achievement of the equivalent outcome at the 2-year timepoint for the contralateral hip. The strongest correlation between improvement in PRO scores for the index and contralateral hips was noted in patients who underwent staged hip arthroscopy within less than 3 months. CONCLUSION Patients experience significant clinical benefit in both hips after staged bilateral hip arthroscopy. Results from the initial hip arthroscopy at either 1- or 2-year follow-up can be used to predict outcomes on the contralateral side; however, there is a higher degree of predictive value using 2-year results. Average correlations between 2-year PROs on the index and contralateral hips were moderate to strong, regardless of the time between surgeries. LEVEL OF EVIDENCE Level III, retrospective cohort study.
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Affiliation(s)
- Nolan S Horner
- Section of Young Adult Hip Surgery, Division of Sports Medicine, Department of Orthopedic Surgery, Rush Medical College of Rush University, Rush University Medical Center, Chicago, Illinois
| | - Morgan W Rice
- Section of Young Adult Hip Surgery, Division of Sports Medicine, Department of Orthopedic Surgery, Rush Medical College of Rush University, Rush University Medical Center, Chicago, Illinois.
| | - Lakshmanan Sivasundaram
- Section of Young Adult Hip Surgery, Division of Sports Medicine, Department of Orthopedic Surgery, Rush Medical College of Rush University, Rush University Medical Center, Chicago, Illinois
| | - Thomas Alter
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, U.S.A
| | - Christopher G Ephron
- Section of Young Adult Hip Surgery, Division of Sports Medicine, Department of Orthopedic Surgery, Rush Medical College of Rush University, Rush University Medical Center, Chicago, Illinois
| | - Shane J Nho
- Section of Young Adult Hip Surgery, Division of Sports Medicine, Department of Orthopedic Surgery, Rush Medical College of Rush University, Rush University Medical Center, Chicago, Illinois
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27
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Hassan MM, Farooqi AS, Feroe AG, Lee A, Cusano A, Novais E, Wuerz TH, Kim YJ, Parisien RL. Open and arthroscopic management of femoroacetabular impingement: a review of current concepts. J Hip Preserv Surg 2022; 9:265-275. [PMID: 36908557 PMCID: PMC9993460 DOI: 10.1093/jhps/hnac043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Revised: 08/09/2022] [Accepted: 10/05/2022] [Indexed: 03/14/2023] Open
Abstract
Femoroacetabular impingement (FAI) is a common femoral and/or acetabular abnormality that can cause progressive damage to the hip and osteoarthritis. FAI can be the result of femoral head/neck overgrowth, acetabular overgrowth or both femoral and acetabular abnormalities, resulting in a loss of native hip biomechanics and pain upon hip flexion and rotation. Radiographic evidence can include loss of sphericity of the femoral neck (cam impingement) and/or acetabular retroversion with focal or global overcoverage (pincer impingement). Operative intervention is indicated in symptomatic patients after failed conservative management with radiographic evidence of impingement and minimal arthritic changes of the hip, with the goal of restoring normal hip biomechanics and reducing pain. This is done by correcting the femoral head-neck relationship to the acetabulum through femoral and/or acetabular osteoplasty and treatment of concomitant hip pathology. In pincer impingement cases with small lunate surfaces, reverse periacetabular osteotomy is indicated as acetabular osteoplasty can decrease an already small articular surface. While surgical dislocation is regarded as the traditional gold standard, hip arthroscopy has become widely utilized in recent years. Studies comparing both open surgery and arthroscopy have shown comparable long-term pain reduction and improvements in clinical measures of hip function, as well as similar conversion rates to total hip arthroplasty. However, arthroscopy has trended toward earlier improvement, quicker recovery and faster return to sports. The purpose of this study was to review the recent literature on open and arthroscopic management of FAI.
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Affiliation(s)
- Mahad M Hassan
- TRIA Orthopedic Center, 8100 Northland Dr, Bloomington, MN 55431, USA.,Department of Orthopaedic Surgery, University of Minnesota Medical School, 2450 Riverside Ave, Suite R200, Minneapolis, MN 55454, USA
| | - Ali S Farooqi
- Perelman School of Medicine at the University of Pennsylvania, 3400 Civic Center Blvd, Philadelphia, PA 19104, USA
| | - Aliya G Feroe
- Department of Orthopedic Surgery, Mayo Clinic, 200 1st St SW, Rochester, MN 55905, USA.,Department of Orthopaedic Surgery, Boston Children's Hospital, Harvard Medical School, 300 Longwood Avenue, Boston, MA 02115, USA
| | - Alexander Lee
- Perelman School of Medicine at the University of Pennsylvania, 3400 Civic Center Blvd, Philadelphia, PA 19104, USA
| | - Antonio Cusano
- University of Connecticut School of Medicine, 200 Academic Way, Farmington, CT 06032, USA
| | - Eduardo Novais
- Department of Orthopaedic Surgery, Boston Children's Hospital, Harvard Medical School, 300 Longwood Avenue, Boston, MA 02115, USA
| | - Thomas H Wuerz
- Boston Sports & Shoulder Center, 840 Winter St, Waltham, MA 02451, USA
| | - Young-Jo Kim
- Department of Orthopaedic Surgery, Boston Children's Hospital, Harvard Medical School, 300 Longwood Avenue, Boston, MA 02115, USA
| | - Robert L Parisien
- Department of Orthopaedic Surgery and Sports Medicine, 5 East 98th Street, Mount Sinai, New York, NY 10029, USA
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28
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Ramkumar PN, Helm JM, Berrier AS, Vega JF, Yalcin S, Kunze KN, Harris JD, Nwachukwu BU. Preoperative Magnetic Resonance Imaging Offers Questionable Clinical Utility, Delays Time to Hip Arthroscopy, and Lacks Cost-Effectiveness in Patients Aged ≤40 Years With Femoroacetabular Impingement Syndrome: A Retrospective 5-Year Analysis. Arthroscopy 2022; 38:3013-3019. [PMID: 35364263 DOI: 10.1016/j.arthro.2022.03.025] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2022] [Revised: 03/11/2022] [Accepted: 03/11/2022] [Indexed: 02/02/2023]
Abstract
PURPOSE To assess the clinical utility of preoperative magnetic resonance imaging (MRI) and quantify the delay in surgical care for patients aged ≤40 years undergoing primary hip arthroscopy with history, physical examination, and radiographs concordant with femoroacetabular impingement syndrome (FAIS). METHODS From August 2015 to December 2020, 1,786 consecutive patients were reviewed from the practice of 1 fellowship-trained hip arthroscopist. Inclusion criteria were FAIS, primary surgery, and age ≤40 years. Exclusion criteria were MRI contraindication, reattempt of conservative management, or concomitant periacetabular osteotomy. After nonoperative treatment options were exhausted and a surgical plan was established, patients were stratified by those who presented with versus without MRI. Those without existing MRI received one, and any deviations from the surgical plan were noted. All preoperative MRIs were compared with office evaluation and intraoperative findings to assess agreement. Demographic data, Hip Disability and Osteoarthritis Outcome Score (HOOS)-Pain, and time from office to MRI or arthroscopy were recorded. RESULTS Of the patients indicated by history, physical examination, and radiographs alone (70% female, body mass index 24.8 kg/m2, age 25.9 years), 198 patients presented without MRI and 934 with MRI. None of the 198 had surgical plans altered after MRI. Patients in both groups had MRI findings demonstrating anterosuperior labral tears that were visualized and repaired intraoperatively. Mean time from office to arthroscopy for patients without MRI versus those with was 107.0 ± 67 and 85.0 ± 53 days, respectively (P < .001). Time to MRI was 22.8 days. No difference between groups was observed among the 85% of patients who surpassed the HOOS-Pain minimal clinically important difference (MCID). CONCLUSION Once indicated for surgery based on history, physical examination, and radiographs, preoperative MRI did not alter the surgical plan for patients aged ≤40 years with FAIS undergoing primary hip arthroscopy. Moreover, preoperative MRI delayed time to arthroscopy. The necessity of routine preoperative MRI in the young primary FAIS population should be challenged.
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Affiliation(s)
- Prem N Ramkumar
- Department of Orthopaedic Surgery, Brigham & Women's Hospital, Boston, Massachusetts, U.S.A.; Center for Hip Preservation, Hospital for Special Surgery, New York, New York, U.S.A..
| | - J Matthew Helm
- Department of Orthopaedic Surgery, McGovern Medical School University of Texas Health Science Center, Houston, Texas, U.S.A
| | - Ava S Berrier
- Department of Orthopaedic Surgery, Baylor College of Medicine, Houston, Texas, U.S.A
| | - Jose F Vega
- Sports Health Center, Cleveland Clinic, Cleveland, Ohio, U.S.A
| | - Sercan Yalcin
- Department of Sports Medicine, Yale School of Medicine, New Haven, Connecticut, U.S.A
| | - Kyle N Kunze
- Center for Hip Preservation, Hospital for Special Surgery, New York, New York, U.S.A
| | - Joshua D Harris
- Houston Methodist Orthopedics & Sports Medicine, Houston, Texas, U.S.A
| | - Benedict U Nwachukwu
- Center for Hip Preservation, Hospital for Special Surgery, New York, New York, U.S.A
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29
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Egger AC, Minkara A, Parker R, Rosneck J. Intra-articular Hip Injuries in National Basketball Association Players: A Descriptive Epidemiological Study. Orthop J Sports Med 2022; 10:23259671221122744. [PMID: 36157088 PMCID: PMC9490462 DOI: 10.1177/23259671221122744] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2022] [Accepted: 07/06/2022] [Indexed: 11/22/2022] Open
Abstract
Background: Since the most recent epidemiologic study of injuries in National Basketball Association (NBA) players was completed in 2012, the understanding and diagnosis of intra-articular hip injury has advanced. Purpose: To report the epidemiology of intra- versus extra-articular hip injuries in NBA players with regard to missed games, risk factors for injury, and treatment types. Study Design: Cohort study; Level of evidence, 3. Methods: The NBA injury database was queried for all reported hip and groin injuries from 2013 to 2017. The injuries were then divided into intra-articular and extra-articular types. Variables compared between injury types included player age, NBA tenure, season schedule (preseason or offseason), onset type, injury mechanism, roster position, games missed, time to return to play, and need for surgery. Results: A total of 224 athletes sustaining 353 total hip pathologies were identified. Of these injuries, 216 (61.2%) were sustained during game competition and affected 156 (69.6%) of the athletes. Intra-articular injuries represented 39 (11.0%) cases and involved 36 (16.1%) players. The time to return to play was significantly longer after intra-articular versus extra-articular injury (44.6 ± 96.0 vs 11.8 ± 32.0 days; P = .03), and the number of games missed was significantly greater after intra-articular versus extra-articular injury (8.0 ± 18.7 vs 1.54 ± 4.9 games; P = .03). Patients with intra-articular hip injuries were more likely to undergo surgery (odds ratio, 5.5 [95% CI, 1.8-16.7]; P = .005). There was no statistically significant difference in the number of games missed due to surgery (35.2 ± 8.3 [intra-articular] vs 35.4 ± 11.6 [extra-articular]; P = .42) or nonoperative treatment (4.2 ± 3.4 [intra-articular] vs 1.3 ± 0.5 [extra-articular]; P = .11). Years of NBA tenure were not significantly different between intra-articular and extra-articular injuries (7.1 ± 3.7 vs 6.3 ± 4.0 years). For both types of hip injury, there was no correlation between player age and either days to return to play or number of games missed (R2 = 0.014). Conclusion: NBA players with intra-articular hip injuries underwent surgery more frequently and had a longer return-to-play time compared with those with extra-articular hip injuries. NBA tenure and player age were not correlated with the risk of developing hip injury or the need for surgery.
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Affiliation(s)
| | - Anas Minkara
- Cleveland Clinic Foundation, Garfield Heights, Ohio, USA
| | - Richard Parker
- Cleveland Clinic Foundation, Garfield Heights, Ohio, USA
| | - James Rosneck
- Cleveland Clinic Foundation, Garfield Heights, Ohio, USA
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30
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Fortier LM, Popovsky D, Durci MM, Norwood H, Sherman WF, Kaye AD. An Updated Review of Femoroacetabular Impingement Syndrome. Orthop Rev (Pavia) 2022; 14:37513. [PMID: 36034731 PMCID: PMC9404268 DOI: 10.52965/001c.37513] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2023] Open
Abstract
Femoroacetabular impingement (FAI) is a chronic hip condition caused by femoral head and acetabular malformations resulting in abnormal contact across the joint. FAI often leads to labral, cartilaginous, and tissue damage that predispose this patient population to early osteoarthritis (OA). There are a variety of factors that increase the risk for FAI including younger age, Caucasian background, familial FAIS morphology, and competing in high-intensity sports during adolescence. Slow-onset, persistent groin pain is the most frequent initial presenting symptom. On physical examination, patients will typically have a positive FADIR test (flexion, adduction, internal rotation), also known as a positive impingement sign. FAI syndrome can be organized into three classifications; cam, pincer, or mixed. This classification refers to the characteristic morphological changes of the bony structures. The primary imaging modality for diagnosing FAI is a plain radiograph of the pelvis, which can be used to measure the alpha angle and the lateral center edge angle used to quantify severity. Conservative treatment is typically considered first-line treatment for mild to moderate FAI syndrome; however, the outcomes following postoperative surgical intervention have demonstrated excellent results. The most common surgical treatment option for FAI is done arthroscopically.
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Affiliation(s)
| | | | - Maggie M Durci
- Louisiana State University Shreveport School of Medicine
| | - Haley Norwood
- Louisiana State University Shreveport School of Medicine
| | | | - Alan D Kaye
- Department of Anesthesiology, Louisiana State University Health Shreveport
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Outcomes in Pediatric Hip FAI Surgery: a Scoping Review. Curr Rev Musculoskelet Med 2022; 15:362-368. [PMID: 35917094 DOI: 10.1007/s12178-022-09771-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/01/2022] [Indexed: 10/16/2022]
Abstract
PURPOSE OF REVIEW Femoracetabular impingement (FAI) is a common source of hip pain in children and adolescents. While nonoperative therapies and open surgical procedures can be effective, hip arthroscopy is a minimally invasive treatment option with substantial benefit. The purpose of this paper is to evaluate the current role of hip arthroscopy in treating FAI within the pediatric population. This article examines its efficacy through a review of hip arthroscopy outcomes in the contemporary orthopaedic literature. RECENT FINDINGS Morphologic changes in the acetabulum and proximal femur seen in FAI can be attributed to a multitude of etiologies-including idiopathic FAI, Legg-Calve-Perthes, and slipped capital femoral epiphysis. In general, arthroscopic treatment of FAI secondary to these conditions leads to statistically significant improvements in pain and patient-reported outcomes in the short and long term. In the pediatric athlete, repetitive stress on the hip perpetuates FAI and can drastically hinder performance. Hip arthroscopy allows for a high rate of return to sport with minimal morbidity in this population. Overall, pediatric hip arthroscopy is effective in treating FAI secondary to a wide variety of conditions. Despite its clinical benefits, patients and their families should be counseled regarding alternative treatments, potential complications, and return to play.
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Mullins K, Filan D, Carton P. Platelet-Rich Plasma Is Not Associated With Improved Outcomes Following Hip Femoroacetabular Impingement Surgery: Very Low-Quality Evidence Suggests Hyaluronic Acid and Cell-Based Therapies May Be Beneficial—A Systematic Review of Biological Treatments. Arthrosc Sports Med Rehabil 2022; 4:e1557-e1573. [PMID: 36033174 PMCID: PMC9402476 DOI: 10.1016/j.asmr.2022.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Accepted: 05/01/2022] [Indexed: 11/19/2022] Open
Abstract
Purpose To examine the efficacy of biologic agents in the treatment of cartilage defects associated with femoroacetabular impingement (FAI). Methods PubMed, Ovid MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, and the Cochrane Database of Systematic Reviews were reviewed by 2 independent reviewers for eligible studies. We included randomized and nonrandomized control trials as well as uncontrolled case series and retrospective studies. Studies were excluded if they included injections of corticosteroids, papers that described technique only, review papers, and those not in the English language. Demographics, treatment type, outcome of treatment, and complications were extracted, whereas risk of bias and study quality were assessed independently using the risk of bias tool (ROB2) and effective public health practice project tool. A narrative synthesis was performed, and standardized mean differences were reported. Certainty of evidence was assessed using the GRADE approach. Results Eighteen studies consisting of 1,024 patients met the inclusion criteria. Three studies involved the use of platelet-rich plasma (PRP) as an adjuvant to surgery and were included in the meta-analysis. Three studies administered hyaluronic acid (HA) as a primary treatment. Twelve involved various cell-based methods of chondrocyte stimulation for cartilage defects associated with FAI, but heterogeneity did not allow for pooling. Low-quality evidence indicates PRP is not associated with improved outcomes following surgery (mean difference –1.42, 95% confidence interval –3.95 to 1.11, P = .27). Very-low-quality evidence suggests HA (standardized mean difference 1.15, 95% confidence interval 0.64-1.66, P < .001, Z = 4.39) and cell-based therapies may improve function and pain in patients with FAI. Conclusions Low-quality evidence indicates PRP is not associated with improved outcomes following hip FAI surgery, and very-low-quality evidence suggests HA and cell-based therapies may improve outcomes. Level of Evidence systematic review of Level I-V studies.
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Affiliation(s)
- Karen Mullins
- UPMC Sports Medicine Clinic, WIT Arena, Waterford, Ireland
- Address correspondence to Karen Mullins, UPMC Sports Medicine Clinic, WIT Arena, Cork Rd., Waterford, Ireland.
| | - David Filan
- UPMC Sports Medicine Clinic, WIT Arena, Waterford, Ireland
| | - Patrick Carton
- UPMC Sports Medicine Clinic, WIT Arena, Waterford, Ireland
- The Hip and Groin Clinic, UPMC Whitfield, Butlerstown North, Waterford, Ireland
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The minimal clinically important difference for the nonarthritic hip score at 2-years following hip arthroscopy. Knee Surg Sports Traumatol Arthrosc 2022; 30:2419-2423. [PMID: 34738159 DOI: 10.1007/s00167-021-06756-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2020] [Accepted: 09/27/2021] [Indexed: 10/19/2022]
Abstract
PURPOSE The purpose of this study was to determine and establish the MCID for the NAHS at 2 years in patients undergoing hip arthroscopy for femoroacetabular impingement syndrome (FAIS). METHODS Patients that underwent primary hip arthroscopy for FAIS between 2010 and 2016 were analyzed for eligibility. Data were collected from a single surgeon's hip arthroscopy database. MCID was calculated for the NAHS utilizing a distribution-based method. RESULTS The study included 298 patients (184 females) with an average age of 40.4 ± 13.0 years and average body mass index (BMI) of 25.7 ± 4.2 kg/m2. At baseline, the cohort's average NAHS score was 48.7 ± 13.6 and demonstrated an improvement of 36.5 ± 17.0 for NAHS at follow-up. This resulted in MCID values of + 8.5 for NAHS. CONCLUSION This is the first study to report the MCID (+ 8.5) for NAHS following primary hip arthroscopy, and as such, is a valuable contribution to future hip arthroscopy research. LEVEL OF EVIDENCE IV.
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Cho YJ, Rhyu KH, Chun YS, Kim MS. Patterns of labral tears and cartilage injury are different in femoroacetabular impingement and dysplasia. J Hip Preserv Surg 2022; 9:151-157. [PMID: 35992029 PMCID: PMC9389910 DOI: 10.1093/jhps/hnac026] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Revised: 03/09/2022] [Accepted: 05/05/2022] [Indexed: 11/13/2022] Open
Abstract
The aim of this study was to assess injury patterns and risk factors of the acetabular labrum and associated cartilage in patients with femoroacetabular impingement (FAI) versus dysplasia. We retrospectively reviewed 137 patients diagnosed with labral tears and FAI or dysplasia (74 or 63 cases, respectively) through an arthroscopic procedure. Labral and concomitant cartilage injuries were evaluated. Demographics and radiological variables [lateral center-edge angle (LCEA), anterior center-edge angle, acetabular index (AI), acetabular version and alpha angle] were evaluated as risk factors for labral and cartilage injuries. Detachment of acetabular cartilage with intact labro-cartilaginous junction was the most common in dysplasia, whereas cartilage delamination from the labro-cartilaginous junction was more common in FAI (P < 0.001). A higher body mass index was significantly associated with delamination injury in FAI (odds ratio 1.226; 95% CI 1.043–1.441; P = 0.013). A significant correlation was evident between detachment injury and a larger AI in dysplasia (odds ratio 1.127; 95% CI 1.000–1.270; P = 0.049). In addition, symptom duration was positively correlated with the extent of labral tearing in FAI (P = 0.013), whereas the smaller LCEA was correlated with the larger extent of labral tearing in dysplasia (P = 0.044). FAI and dysplasia patients exhibited different labral and cartilage injury patterns. Increased body mass index was correlated with delamination injury in FAI, whereas an increased AI was associated with detachment injury in dysplasia. Greater tearing was associated with a longer symptom duration in FAI, and a decreased LCEA was a risk factor for the extent of tearing in dysplasia.
Level of evidence
Level III. Case–control study.
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Affiliation(s)
- Yoon-Je Cho
- Department of Orthopaedic Surgery, College of Medicine , Kyung Hee University Hospital, 23 Kyung Hee Dae-ro, Dongdaemoon-ku, Seoul 02447, Republic of Korea
| | - Kee-Hyung Rhyu
- Department of Orthopaedic Surgery, College of Medicine , Kyung Hee University Hospital, 23 Kyung Hee Dae-ro, Dongdaemoon-ku, Seoul 02447, Republic of Korea
| | - Young-Soo Chun
- Department of Orthopaedic Surgery, College of Medicine , Kyung Hee University Hospital at Gangdong, 892 Dongnam-ro, Gangdong-ku, Seoul 05278, Republic of Korea
| | - Myung-Seo Kim
- Department of Orthopaedic Surgery, College of Medicine , Kyung Hee University Hospital at Gangdong, 892 Dongnam-ro, Gangdong-ku, Seoul 05278, Republic of Korea
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Clement RC. "Nonoperative Management of Femoroacetabular Impingement in Adolescents: Clinical Outcomes at a Mean of 5 Years: A Prospective Study": Letter to the Editor. Am J Sports Med 2022; 50:NP29-NP30. [PMID: 35507466 DOI: 10.1177/03635465221079311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
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Budde S, Ezechieli M. [Management of FAIS in professional soccer athletes and return to sports]. DER ORTHOPADE 2022; 51:466-471. [PMID: 35482052 DOI: 10.1007/s00132-022-04257-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 04/06/2022] [Indexed: 10/18/2022]
Abstract
The prevalence of femoroacetabular impingement syndrome in professional soccer athletes is high. Professional training and treatment conditions ensure an effective conservative therapy focusing on dynamic stability, motion control, muscle balance and core stability. In the case of persistent limitations, indication for surgery has to be considered carefully. The probability is high that return to a professional level of soccer is feasible. However, the period of rehabilitation is long, leading to a potential conflict area between economic and medical interests. Good communication and intensive patient education are essential.
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Affiliation(s)
- Stefan Budde
- Klinik für Unfallchirurgie und Orthopädie, Evangelisches Klinikum Bethel, Universitätsklinikum OWL der Universität Bielefeld, Burgsteig 13, 33617, Bielefeld, Deutschland.
| | - Marco Ezechieli
- Vincenz Krankenhaus Paderborn, Standort Salzkotten, Salzkotten, Deutschland
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Mahmoud SSS, Takla A, Meyer D, Griffin D, O’Donnell J. Arthroscopic hip surgery offers better early patient-reported outcome measures than targeted physiotherapy programs for the treatment of femoroacetabular impingement syndrome: a systematic review and meta-analysis of randomized controlled trials. J Hip Preserv Surg 2022; 9:107-118. [PMID: 35854801 PMCID: PMC9291355 DOI: 10.1093/jhps/hnac012] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2022] [Revised: 03/01/2021] [Accepted: 02/10/2022] [Indexed: 02/04/2023] Open
Abstract
Targeted physiotherapy programs (TPP), and surgery, using either open surgical hip dislocation or hip arthroscopy (HA), are the treatment modalities available for femoroacetabular impingement syndrome (FAIS). Randomized controlled trials have recently been performed to compare these treatment options. This review was performed to provide a focused synthesis of the available evidence regarding the relative value of treatment options. A systematic search was performed of Medline, Embase, Cochrane Library and ClinicalTrials.gov databases. Inclusion criteria were randomized controlled trials comparing treatment methods. The Cochrane Risk of Bias assessment tool (RoB2) was used to assess the selected studies. A meta-analysis was performed between homogenous studies. Four trials were identified including 749 patients (392 males). The mean ages of the cohorts ranged between 30.1 and 36.2 years old. Three hundred thirty-five patients underwent HA by 46 surgeons among all trials. Fifty-two patients crossed over from the TPP to the HA group. One of the trials was found to have a high risk of bias, while the other three were between low risk and some concerns. The iHOT-33 was the most commonly used patient-reported outcome measure followed by the HOS ADL and EQ-5D-5L. Others scores were also identified. Scores from two trials could be pooled together for meta-analysis. Apart from SF-12 and GRC, all other scores have shown significantly better outcomes with HA in comparison to TPP at 8- and 12-months follow-up points. HA offers better patient-reported outcomes than TPP for management of FAIS at 8- and 12-months follow-up.
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Affiliation(s)
- Samer S S Mahmoud
- Hip Arthroscopy Australia, 21 Erin Street, Richmond, VIC 3121, Australia
| | - Amir Takla
- Department of Health Professions, Faculty of Health, Arts and Design, Sports & Musculoskeletal Physiotherapist, Australian Sports Physiotherapy, Swinburne University of Technology, Hip Arthroscopy Australia, 21 Erin Street, Richmond, VIC 3121, Australia
| | - Denny Meyer
- Department of Health Sciences and Biostatistics, School of Health, Swinburne University of Technology, PO Box 218, Hawthorn, VIC 3122, Australia
| | - Damian Griffin
- Department of Orthopaedic Surgery, University of Warwick, University Hospitals of Coventry and Warwickshire NHS Trust, Clifford Bridge Road, Coventry CV2 2DX, UK
| | - John O’Donnell
- Department of Orthopaedics, Swinburne University of Technology, PO Box 218, Hawthorn, VIC 3122, Australia
- Hip Arthroscopy Australia, 21 Erin Street, Richmond, VIC 3121, Australia
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Kumar MV, Shanmugaraj A, Kay J, Simunovic N, Huang MJ, Wuerz TH, Ayeni OR. Bilateral hip arthroscopy for treating femoroacetabular impingement: a systematic review. Knee Surg Sports Traumatol Arthrosc 2022; 30:1095-1108. [PMID: 34165631 DOI: 10.1007/s00167-021-06647-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Accepted: 06/18/2021] [Indexed: 02/07/2023]
Abstract
PURPOSE Femoroacetabular impingement (FAI) is a hip disorder which can often present bilaterally. The purpose of this systematic review was to explore the current practices for bilateral hip arthroscopy in treating FAI as they relate to outcomes and complications. METHODS This review has been conducted according to the guidelines of Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA). The electronic databases PubMed, MEDLINE, EMBASE, and CENTRAL (Cochrane Central Register of Controlled Trials) were searched from data inception to October 18th, 2020. The Methodological Index for Non-randomized Studies (MINORS) was used to assess study quality. Data are presented descriptively. RESULTS Overall, 19 studies were identified, comprising 957 patients (48.6% male) with a mean age of 27.9 ± 7.1 years and a mean follow-up of 31.7 ± 20.8 months. The majority of patients were treated with a staged bilateral hip arthroscopy (78.5%) with a mean duration between surgeries of 7.1 ± 4.0 months. Significant preoperative-to-postoperative improvements for clinical outcomes such as pain, hip function, and health-related daily living as well as radiographic outcomes were reported in six studies for staged procedures (p < 0.05) and three studies for simultaneous procedures (p < 0.02). Significant improvements in patient-reported outcomes (e.g., HOS-ADL, Pain, HOS-SS, mHHS, and NAHS) were found in favor of those undergoing a shorter delay between surgeries in three studies (i.e., < 3, 10 or 17 months) (p < 0.05) compared to those who had delayed surgeries (i.e., > 3, 10, or 17 months). The overall complication rate was 10.1% (97/957). CONCLUSIONS Bilateral surgery for FAI yields improved outcomes postoperatively and complication rates similar to unilateral surgery. The overall complication rate was 10.1% with the most common complication being revision surgery. Staged bilateral surgery is more commonly performed than simultaneous surgery. Clinicians should consider preoperative imaging, clinical history, and patient values when deciding between staged and simultaneous procedures for bilateral FAI surgery. Future studies are required to determine the optimal indications for simultaneous versus staged procedures, as well as the ideal timing between surgeries for the latter. LEVEL OF EVIDENCE Level IV.
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Affiliation(s)
- Mithilesh V Kumar
- Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
| | - Ajaykumar Shanmugaraj
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, ON, Canada
| | - Jeffrey Kay
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, ON, Canada
| | - Nicole Simunovic
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, ON, Canada
| | - Michael J Huang
- Colorado Springs Orthopaedic Group, Colorado Springs, CO, USA
| | | | - Olufemi R Ayeni
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, ON, Canada. .,McMaster University Medical Centre, 1200 Main St W, Room 4E15, Hamilton, ON, L8N 3Z5, Canada.
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Abstract
BACKGROUND Hip microinstability has recently gained acceptance as a cause of hip pain. In this condition, the femoral head demonstrates increased motion relative to the acetabulum, which may lead to chondrolabral damage. Even though patients are initially prescribed a trial of nonoperative treatment, the success rates of rehabilitation are unknown. PURPOSE To determine the success rate of nonoperative treatment of hip microinstability. STUDY DESIGN Case series; Level of evidence, 4. METHODS After institutional review board approval was obtained, a retrospective chart review was performed on patients at a university sports medicine practice between January 2013 and July 2016. All patients older than 18 years presenting with hip microinstability who were initially recommended for treatment with physical therapy were enrolled in this study. Formal physical therapy sessions focused on strengthening the hip and core muscles. These sessions took place twice a week for a minimum of 6 weeks in conjunction with a home exercise program. The number of patients who eventually underwent surgical treatment and the clinical scores for the cohort (modified Harris Hip Score [mHHS] and 33-item International Hip Outcome Tool) were recorded. RESULTS A total of 64 patients (63 female, 1 male), with a mean ± SD age of 32.2 ± 10.5 years, were identified and studied. Onset of symptoms was insidious (n = 45; 70.3%), acute atraumatic (n = 12; 18.8%), and traumatic (n = 7; 10.9%). A total of 9 (14.1%) patients were high-level athletes. After a follow-up of 45.7 ± 14.6 months, 14 (29.8%) patients eventually underwent hip arthroscopy for persistent hip pain. Capsular plication was performed in all surgical cases. High-level athletes were not more likely to need surgery (50% vs 26.8%; P = .34). The mHHS was available in 24 patients who were treated nonoperatively, and it improved from 67.4 to 85.0 (P < .01). CONCLUSION More than two-thirds of patients treated for hip microinstability were able to avoid surgery; they were successfully treated nonoperatively with physical therapy and a home exercise program and demonstrated improved clinical outcome scores.
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Affiliation(s)
- Leandro Ejnisman
- Stanford University, Redwood City, California, USA.,Instituto de Ortopedia e Traumatologia, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brazil.,Hospital Israelita Albert Einstein, Sao Paulo, Brazil
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Kawai M, Tateda K, Ikeda Y, Kosukegawa I, Nagoya S, Katayose M. The Short-term Outcomes of Physiotherapy for Patients with Acetabular Labral Tears: An Analysis according to Severity of Injury in Magnetic Resonance Imaging. Hip Pelvis 2022; 34:45-55. [PMID: 35355626 PMCID: PMC8931951 DOI: 10.5371/hp.2022.34.1.45] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Revised: 06/21/2021] [Accepted: 06/25/2021] [Indexed: 11/24/2022] Open
Abstract
Purpose The aim of this study was to evaluate the short-term outcome of physiotherapy in patients with acetabular labral tears and to assess the effectiveness of physiotherapy according to the severity of the labral tear. Materials and Methods Thirty-five patients who underwent physiotherapy for treatment of symptomatic acetabular labral tears were enrolled. We evaluated the severity of the acetabular labral tears, which were classified based on the Czerny classification system using 3-T MRI. Clinical findings of microinstability and extra-articular pathologies of the hip joint were also examined. The International Hip Outcome Tool 12 (iHOT12) was use for evaluation of outcome scores pre- and post-intervention. Results The mean iHOT12 score showed significant improvement from 44.0 to 73.6 in 4.7 months. Compared with pre-intervention scores, significantly higher post-intervention iHOT12 scores were observed for Czerny stages I and II tears (all P<0.01). However, no significant difference was observed between pre-intervention and post-intervention iHOT12 scores for stage III tears (P=0.061). In addition, seven patients (20.0%) had positive microinstability findings and 22 patients (62.9%) had findings of extra-articular pathologies. Of the 35 patients, eight patients (22.9%) underwent surgical treatment after failure of conservative management; four of these patients had Czerny stage III tears. Conclusion The iHOT12 score of patients with acetabular labral tears was significantly improved by physiotherapy in the short-term period. Improvement of the clinical score by physiotherapy may be poor in patients with severe acetabular labral tears. Determining the severity of acetabular labral tears can be useful in determining treatment strategies.
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Affiliation(s)
- Makoto Kawai
- Department of Rehabilitation, Sapporo Medical University Hospital, Sapporo, Japan.,Second Division of Physical Therapy, School of Health Sciences, Sapporo Medical University, Sapporo, Japan
| | - Kenji Tateda
- Department of Orthopaedic Surgery, Sapporo Medical University School of Medicine, Sapporo, Japan
| | - Yuma Ikeda
- Department of Rehabilitation, Sapporo Medical University Hospital, Sapporo, Japan
| | - Ima Kosukegawa
- Department of Orthopaedic Surgery, Sapporo Medical University School of Medicine, Sapporo, Japan
| | - Satoshi Nagoya
- Department of Musculoskeletal Biomechanics and Surgical Development, Sapporo Medical University, Sapporo, Japan
| | - Masaki Katayose
- Department of Rehabilitation, Sapporo Medical University Hospital, Sapporo, Japan.,Second Division of Physical Therapy, School of Health Sciences, Sapporo Medical University, Sapporo, Japan
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Cheng AL, Collis RW, McCullough AB, Bui M, Brady BK, Schuelke MJ, Clohisy JC, Colditz GA, Prather H. Rate of continued conservative management versus progression to surgery at minimum one year follow-up in patients with pre-arthritic hip pain. PM R 2021; 14:575-586. [PMID: 34894417 PMCID: PMC9149117 DOI: 10.1002/pmrj.12746] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Revised: 10/28/2021] [Accepted: 11/29/2021] [Indexed: 11/10/2022]
Abstract
INTRODUCTION Extensive literature has described surgical outcomes for pre-arthritic hip pain, but the proportion of patients who progress to surgery remains unknown. OBJECTIVE To determine the proportion of patients who present to a tertiary referral center for pre-arthritic hip pain and progress to surgery at minimum one year follow-up. DESIGN Retrospective cohort study. SETTING Single tertiary care academic medical center. PATIENTS Thirteen to 40-year-olds who presented for initial evaluation to a conservative or surgical orthopedic specialist and were diagnosed with pre-arthritic hip pain (n=713 patients, 830 hips). INTERVENTION Not applicable. MAIN OUTCOME MEASURES The primary outcome was the rate of progression to surgery at minimum one year follow-up for the entire cohort. Predictors of progression to surgery were determined for the entire cohort and for radiographically defined subgroups using multiple logistic regression. Candidate predictors included baseline demographic, radiographic, clinical diagnosis, and patient-reported outcome measures. RESULTS In a cohort with mean age 25.4 (SD 8.1) years, 72.7% female, and mean follow-up 2.6 (range 1.0-4.8) years, 429/830 hips (51.7% [95% CI 48.2%-55.1%]) progressed to surgery. Predictors of surgical progression in the entire cohort included younger age (OR 0.95/year [95% CI 0.93-0.98]), pain duration longer than six months (OR 1.87-2.03, p≤.027), worse physical function (OR 0.96/Patient-Reported Outcomes Measurement Information System (PROMIS) point [0.92-0.99]), and a clinical diagnosis of femoroacetabular impingement (FAI) (OR 3.47 [2.05-5.89]), acetabular dysplasia (OR 2.75 [1.73-4.35]), and/or labral tear (OR 10.71 [6.98-16.47]). Radiographic dysplasia (lateral center edge angle<200 ) increased the likelihood of surgery in all subgroups (OR 2.05-8.47, p≤.008). Increasing maximum α angle increased the likelihood of surgery in patients with severe cam FAI (α>630 ) (OR 1.03/degree [1.00-1.06]). CONCLUSION Almost half of patients with pre-arthritic hip pain did not progress to surgery at minimum one year follow-up. A trial of conservative management is likely worthwhile in most patients. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Abby L Cheng
- Department of Orthopaedic Surgery, Division of Physical Medicine and Rehabilitation, Washington University in St. Louis School of Medicine, St. Louis, MO, USA.,Department of Surgery, Division of Public Health Sciences, Washington University in St. Louis School of Medicine, St. Louis, MO, USA
| | - Reid W Collis
- Washington University in St. Louis School of Medicine, St. Louis, MO, USA
| | - Andrea B McCullough
- Department of Neurology, Division of Physical Medicine and Rehabilitation, St. Louis, MO, USA
| | - Mary Bui
- Saint Louis University School of Medicine, St. Louis, MO, USA
| | - Brian K Brady
- Department of Neurology, Division of Physical Medicine and Rehabilitation, St. Louis, MO, USA
| | - Matthew J Schuelke
- Division of Biostatistics, Washington University in St. Louis School of Medicine, St. Louis, MO, USA
| | - John C Clohisy
- Department of Orthopaedic Surgery, Division of Adult Reconstruction and Hip Preservation, Washington University in St. Louis School of Medicine, St. Louis, MO, USA
| | - Graham A Colditz
- Department of Surgery, Division of Public Health Sciences, Washington University in St. Louis School of Medicine, St. Louis, MO, USA
| | - Heidi Prather
- Weill Cornell Medical College, New York City, NY, USA
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Acetabular labral tears in the adolescent athlete: results of a graduated management protocol from therapy to arthroscopy. J Pediatr Orthop B 2021; 30:549-555. [PMID: 32826727 DOI: 10.1097/bpb.0000000000000793] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
This study sought to determine outcomes of a graduated management protocol from therapy to arthroscopy for adolescents presenting with hip pain and an associated acetabular tear. Thirty-seven hips with an MRI confirmed labral tear were prospectively enrolled in a graduated management protocol created for adolescents. The protocol began with activity modification and focused physical therapy. Patients with persistent symptoms were offered an intraarticular corticosteroid injection. Those with continued symptoms were treated with arthroscopic surgery. The modified Harris hip score (mHHS) and nonarthritic hip score (NAHS) were recorded at the initial visit. Patients were contacted by telephone at 1, 2, and 5 years from enrollment for repeat assessment with mHHS and NAHS. At presentation, the mean mHHS and NAHS for the entire cohort was 66.4 ± 11.4 and 70.2 ± 12.6, and these values improved significantly to 89.3 ± 10.6 and 87.0 ± 11.4 at a mean follow-up of 35.7 ± 18.3 months (range 11.7-64.4 months). Forty-two percent of hips were managed with physical therapy and activity modifications alone, 28% of hips progressed to a steroid injection but did not require surgery, and 31% required arthroscopic intervention. Seventy-three percent of hips treated with activity modification alone, 80% treated with an injection, and 82% of hips treated with arthroscopic repair met the minimal clinically significant difference (MCID) (P = 0.859). At an average of 36 months follow-up, the majority (78%) of adolescent patients with an acetabular labral tear will achieve the MCID utilizing a graduated management protocol.
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Ishøi L, Nielsen MF, Krommes K, Husted RS, Hölmich P, Pedersen LL, Thorborg K. Femoroacetabular impingement syndrome and labral injuries: grading the evidence on diagnosis and non-operative treatment-a statement paper commissioned by the Danish Society of Sports Physical Therapy (DSSF). Br J Sports Med 2021; 55:1301-1310. [PMID: 34531185 DOI: 10.1136/bjsports-2021-104060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/06/2021] [Indexed: 11/03/2022]
Abstract
This statement summarises and appraises the evidence on diagnostic tests and clinical information, and non-operative treatment of femoroacetabular impingement (FAI) syndrome and labral injuries. We included studies based on the highest available level of evidence as judged by study design. We evaluated the certainty of evidence using the Grading of Recommendations Assessment Development and Evaluation framework. We found 29 studies reporting 23 clinical tests and 14 different forms of clinical information, respectively. Restricted internal hip rotation in 0° hip flexion with or without pain was best to rule in FAI syndrome (low diagnostic effectiveness; low quality of evidence; interpretation of evidence: may increase post-test probability slightly), whereas no pain in Flexion Adduction Internal Rotation test or no restricted range of motion in Flexion Abduction External Rotation test compared with the unaffected side were best to rule out (very low to high diagnostic effectiveness; very low to moderate quality of evidence; interpretation of evidence: very uncertain, but may reduce post-test probability slightly). No forms of clinical information were found useful for diagnosis. For treatment of FAI syndrome, 14 randomised controlled trials were found. Prescribed physiotherapy, consisting of hip strengthening, hip joint manual therapy techniques, functional activity-specific retraining and education showed a small to medium effect size compared with a combination of passive modalities, stretching and advice (very low to low quality of evidence; interpretation of evidence: very uncertain, but may slightly improve outcomes). Prescribed physiotherapy was, however, inferior to hip arthroscopy (small effect size; moderate quality of evidence; interpretation of evidence: hip arthroscopy probably increases outcome slightly). For both domains, the overall quality of evidence ranged from very low to moderate indicating that future research on diagnosis and treatment may alter the conclusions from this review.
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Affiliation(s)
- Lasse Ishøi
- Sports Orthopaedic Research Center-Copenhagen (SORC-C), Arthroscopic Center, Department of Orthopedic Surgery, Copenhagen University Hospital, Hvidovre Hospital, Hvidovre, Denmark
| | - Mathias Fabricius Nielsen
- Sports Orthopaedic Research Center-Copenhagen (SORC-C), Arthroscopic Center, Department of Orthopedic Surgery, Copenhagen University Hospital, Hvidovre Hospital, Hvidovre, Denmark
| | - Kasper Krommes
- Sports Orthopaedic Research Center-Copenhagen (SORC-C), Arthroscopic Center, Department of Orthopedic Surgery, Copenhagen University Hospital, Hvidovre Hospital, Hvidovre, Denmark
| | - Rasmus Skov Husted
- Physical Medicine & Rehabilitation Research - Copenhagen (PMR-C), Department of Orthopedic Surgery and Physical Therapy, Copenhagen University Hospital, Hvidovre, Denmark.,Department of Clinical Research, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark
| | - Per Hölmich
- Sports Orthopaedic Research Center-Copenhagen (SORC-C), Arthroscopic Center, Department of Orthopedic Surgery, Copenhagen University Hospital, Hvidovre Hospital, Hvidovre, Denmark
| | | | - Kristian Thorborg
- Sports Orthopaedic Research Center-Copenhagen (SORC-C), Arthroscopic Center, Department of Orthopedic Surgery, Copenhagen University Hospital, Hvidovre Hospital, Hvidovre, Denmark
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Zogby AM, Bomar JD, Johnson KP, Upasani VV, Pennock AT. Nonoperative Management of Femoroacetabular Impingement in Adolescents: Clinical Outcomes at a Mean of 5 Years: A Prospective Study. Am J Sports Med 2021; 49:2960-2967. [PMID: 34357811 DOI: 10.1177/03635465211030512] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND There is a lack of midterm or long-term outcome data on nonoperative management of femoroacetabular impingement (FAI) syndrome in adolescents despite expanding research mostly focused on arthroscopic management. PURPOSE To present 5-year outcome data utilizing a nonoperative protocol on a consecutive series of patients presenting to our clinic with FAI syndrome. STUDY DESIGN Cohort study, Level of evidence, 2. METHODS A total of 100 patients (62% female; mean age 15 years) who presented to the clinic for evaluation of hip pain and had at least 1 hip with a positive impingement sign were prospectively recruited. The management protocol consisted of an initial trial of rest, physical therapy, and activity modification. Patients who remained symptomatic were offered an intra-articular steroid injection. Patients with recurrent symptoms were then offered arthroscopic treatment. Patient-reported outcomes (PROs), including the modified Harris Hip Score (mHHS) and the Nonarthritic Hip Score (NAHS) were then collected at a mean 1, 2, and 5 years after the initial evaluation. RESULTS At enrollment, the mean mHHS and NAHS were 69.6 ± 12.9 and 75.5 ± 15.2, respectively. A total of 51 patients (n = 69 hips) were available at a mean 5-year follow-up, with the mean mHHS and NAHS of 89.5 ± 10.8 and 88.1 ± 12, respectively. There was no significant difference in the mHHS or the NAHS between activity modification and physical therapy, injection, or arthroscopic surgery groups at 5-year follow-up (P > .6) and no difference in the proportion of hips meeting the minimal clinically important difference (MCID) for the mHHS based on treatment course (P = .99). There was no significant difference in the mHHS or the NAHS between FAI types at any time point, or in the proportion of hips that met the MCID among FAI types (P = .64). Also, 11 out of 12 hips that required surgery had surgery in less than 2 years. One hip underwent surgery at 5 years after the initial visit. There was no significant drop-off in the mHHS or the NAHS between the 2-year and 5-year time periods (P > .3). CONCLUSION Nonoperative management of FAI syndrome is effective in a majority of adolescent patients, with significant improvements in PROs persisting at a mean 5-year follow-up.
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Affiliation(s)
- Andrew M Zogby
- University of California, San Diego, California, USA.,Rady Children's Hospital, San Diego, California, USA
| | - James D Bomar
- University of California, San Diego, California, USA.,Rady Children's Hospital, San Diego, California, USA
| | - Kristina P Johnson
- University of California, San Diego, California, USA.,Rady Children's Hospital, San Diego, California, USA
| | - Vidyadhar V Upasani
- University of California, San Diego, California, USA.,Rady Children's Hospital, San Diego, California, USA
| | - Andrew T Pennock
- University of California, San Diego, California, USA.,Rady Children's Hospital, San Diego, California, USA
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Terrell SL, Olson GE, Lynch J. Therapeutic Exercise Approaches to Nonoperative and Postoperative Management of Femoroacetabular Impingement Syndrome. J Athl Train 2021; 56:31-45. [PMID: 33112956 DOI: 10.4085/1062-6050-0488.19] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Femoroacetabular impingement syndrome (FAIS) is characterized by premature contact of the femur and acetabulum during hip motion. Morphologic variations of FAIS present as either aspherical femoral deformity (cam femoroacetabular impingement) or overcoverage (pincer femoroacetabular impingement) or both. Patients with FAIS often describe discomfort with hip flexion, adduction, and internal rotation. The use of hip arthroscopy to treat FAIS has risen substantially over the last 15 years. Given that one practice domain of the athletic training profession involves injury prevention and wellness protection, optimal FAIS treatment and management strategies warrant discussion. Sports medicine professionals often help patients with FAIS explore nonoperative exercise strategies and direct rehabilitation exercises for those who pursue surgery. Both approaches demonstrate key pillars of exercise program design, which include postural control, core stabilization, hip strength and motor control, and mobility. The purpose of this article is 2-fold: to present an overview of FAIS, including common diagnostic strategies, and commonalities in therapeutic approaches between nonoperative and postoperative rehabilitation for the treatment and management of patients with FAIS.
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Affiliation(s)
- Sara Lynn Terrell
- Department of Exercise Science, Florida Southern College, Lakeland.,School of Nursing and Health Sciences, Florida Southern College, Lakeland
| | - Gayle E Olson
- Department of Athletics, Florida Southern College, Lakeland
| | - James Lynch
- School of Nursing and Health Sciences, Florida Southern College, Lakeland
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Nonsurgical Versus Surgical Management of Femoroacetabular Impingement: What Does the Current Best Evidence Tell Us. J Am Acad Orthop Surg 2021; 29:e471-e478. [PMID: 33351525 DOI: 10.5435/jaaos-d-20-00571] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Accepted: 11/15/2020] [Indexed: 02/01/2023] Open
Abstract
Controversy exists as to the management of femoroacetabular impingement (FAI). When nonsurgical management of symptomatic FAI fails, surgical management is generally indicated. However, many groups with a stake in patient care (particularly payors) have insisted on higher levels of evidence. Recently, there have been several Level I studies published, comparing physical therapy (PT) with hip arthroscopy in the management of symptomatic FAI. All of these studies have used outcomes tools developed and validated for patients with nonarthritic hip pain (the International Hip Outcome Tool). Most highest level evidence confirms that although patients with FAI do benefit from PT, patients who undergo surgical management for FAI with hip arthroscopy benefit more than those who undergo PT (mean difference in the International Hip Outcome Tool 6.8 [minimal clinically important difference 6.1], P = 0.0093). Future large prospective studies are needed to evaluate the effect on the outcomes when there is a delay in surgical management in symptomatic individuals, assess whether FAI surgery prevents or delays osteoarthritis, and determine the role of other advanced surgical techniques.
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Hosalkar HS. CORR Insights®: Does the Capital Femoral Physis Bony Morphology Differ in Children with Symptomatic Cam-type Femoroacetabular Impingement. Clin Orthop Relat Res 2021; 479:932-934. [PMID: 33512958 PMCID: PMC8052082 DOI: 10.1097/corr.0000000000001646] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2020] [Accepted: 01/02/2021] [Indexed: 01/31/2023]
Affiliation(s)
- Harish S Hosalkar
- H. S. Hosalkar, Medical Director, Hosalkar Institute for Joint Preservation and Injury Care, Department of Orthopaedics, San Diego, CA, USA
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Make the Right Diagnosis: My Pearls for Working Up Hip-related Pain. Sports Med Arthrosc Rev 2021; 29:2-8. [PMID: 33395223 DOI: 10.1097/jsa.0000000000000288] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The origin of pain around the hip is commonly more elusive than other joints; often obscured by compensatory disorders. Hip problems tend to be multifactorial and require a multidisciplinary approach in the evaluation. The best strategy is to team with a capable physical therapist to unveil the layers of problems. Ultrasonography and imaging/ultrasound-guided injections can be the most valuable adjunct to the history and physical examination. Plain radiographs are an essential element in the workup. Magnetic resonance imaging can underestimate damage in the joint, but positive findings can sometimes be the normal consequence of age and activity. Magnetic resonance imaging is often as important for what it rules out as much as what it rules in. Computed tomography scans with 3-dimensional reconstructions can be especially helpful in surgical planning but are not used in routine screening, being thoughtful of radiation exposure even with low-dose protocols. Arthroscopic access to the hip is more challenging than other joints, and similarly, unlocking its clinical secrets can be more imposing as well.
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Femoroacetabular Impingement and Core Muscle Injury in Athletes: Diagnosis and Algorithms for Success. Sports Med Arthrosc Rev 2021; 29:9-14. [PMID: 33395224 DOI: 10.1097/jsa.0000000000000294] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Athletic hip injuries account for a substantial portion of missed time from sports in high-level athletes. For both femoroacetabular impingement (FAI) and core muscles injuries, a thorough history and physical examination are paramount to guide the treatment. While advanced imaging including computed tomography and magnetic resonance imaging are frequently obtained, a wealth of information can be ascertained from standard radiographs alone. For patients with isolated or combined FAI and core muscle injuries (CMIs), the initial treatment is often nonoperative and consists of rest, activity modification, and physical therapy of the hips, core, and trunk. Injections may then aid in both confirming diagnosis and temporary symptom abatement. Arthroscopic procedures for refractory FAI in experienced hands have been shown to be both safe and efficacious. While surgical repair options for CMIs are significantly more variable, long-term studies have demonstrated the rapid resolution of symptoms and high return to play rates. More recently, anatomic and clinical correlations between FAI and CMIs have been identified. Special attention must be paid to elite athletes as the incidence of concurrent FAI with CMI is extremely high yet with significant symptom variability. Predictable return to play in athletes with coexisting symptomatic intra-articular and extra-articular symptomatology is incumbent upon the treatment of both pathologies.
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Abstract
This article provides concise and up-to-date information on the most common hip pathologies that affect adolescent athletes. We cover the evaluation and treatment of avulsion injuries, stress fractures, slipped capital femoral epiphysis (SCFE), femoroacetabular impingement, developmental dysplasia of the hip, Legg-Calve-Perthes disease, and coxa saltans focusing on minimizing advanced imaging and using conservative therapy when applicable. Although this is not an all-encompassing list of disorders, it is key to understand these hip pathologies because these injuries occur commonly and can also have detrimental complications if not diagnosed and addressed early, especially SCFE and femoral neck stress fractures.
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Affiliation(s)
- Paul B Schroeder
- Department of Orthopaedics, San Antonio Military Medical Center, 3851 Roger Brooke Drive, Fort Sam Houston, TX 78234, USA
| | - Marc A Nicholes
- School of Osteopathic Medicine, University of the Incarnate Word, 7615 Kennedy Hill, Building 1, San Antonio, TX 78234, USA
| | - Matthew R Schmitz
- Department of Orthopaedics, San Antonio Military Medical Center, 3851 Roger Brooke Drive, Fort Sam Houston, TX 78234, USA.
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